ERYTHROCYTE

SEDIMENTATION RATE
( ESR )
Dr. Ayman Najjar
Objectives of this meeting
➢ What is the laboratory test ESR?
➢ History of ESR.
➢ ESR Principle, deeper insight.
➢ Westergren method of ESR determination.
➢ Wintrobe method of ESR determination.
➢ Micro-ESR method.
➢ Automated method.
➢ What factors that affect ESR results?
➢ The three main stages of ESR.
➢ ESR anticoagulants: Citrate vs. EDTA.
 Continue ….. Objectives of this meeting
➢ Old method vs. New methods of ESR measurement.
➢ ESR by cell counter.
➢ Advantages and disadvantages of the ESR test.
➢ Clinically significant of ESR.
➢ How to correct ESR results?
➢ ESR vs. CRP.
➢ESR in the second hour.
➢ Others and discussion.
What is ESR
❖ Erythrocyte sedimentation rate:
• The rate of RBCs falls for a specified period, usually 1 hour.
• Rate, scale=mm and Time=1hour (mm/1hr).

❖ Special graduated Pipette/tube with known diameter.

• Filled by not clotted blood (free RBCs).
• Stand as vertical.
• System stands for 60 minutes.

❖ ESR is a nonspecific test that is used as an indicator of inflammation.

History of ESR
• Biernacki (1897): A physician describes the concept of sedimentation in
blood. He observed that the rate at which red blood cells settle in a test tube
varies in different disease states, particularly in infections and inflammation.
• Fahraeus (1918): A hematologist studied the correlation between blood
sedimentation and pregnancy.
• Westergren (1921): A physician focused on the test’s application in
tuberculosis. They developed a standardized method for measuring the ESR,
known as the Westergren method, which remains the golden standard and is
widely used today.
• Wintrobe (the 1930s): A hematologist used a shorter and narrower tube
than the Westergren tube but still less sensitive.
History of ESR
• 1960s-1980s: using automated systems to measure ESR.
• These instruments improved the reproducibility and accuracy of results.
• Reduced human errors.
• Allows quicker and more efficient measurements.
• 1990s-present: fully automated ESR systems were developed.
• Standardize the procedure, reducing variability and using low blood volume.
• Performing the test in minutes rather than the traditional 60 minutes.
• Point-of-care ESR testing has become more available, enabling ESR
measurements in outpatient settings or smaller clinics.
 Principle of ESR
• Normal red blood cells settle slowly because their
surface charges repel one another.

• Certain proteins in the blood (fibrinogen &

Immunoglobulins), which increase during
inflammation or infection), neutralize red blood
cells’ negative charges that come from sialic acid
and facilitate RBCs to stack together in chains
(rouleaux formation).

• Rouleaux formation settles faster due to increased

density and size, leading to a higher ESR.
Rouleaux formation
The three stages of ESR

1. Rouleaux formation stage: An

initial period of 10 minutes.
2. Sedimentation stage: A period
of approximately 40 minutes.
the second stage is the most
significant phase.
3. Packing stage: A slower rate of
fall (last 10 minutes).
Westergren rack & Pipette
Wintrobe rack & tube
Trisodium citrate used for ESR
3.8 gm powder/100 ml DW
Ratio: 4.0 ml WB to 1.0 ml TSC
ESR Normal Ranges
Sex Westergren Wintrobe
Calculating the maximum
Male 0-10 mm/1st hour 0-9 mm/1st hour ESR result by Age
Female 0-15 mm/1st hour 0-20 mm/1st hour

Pregnant: 1st half of pregnancy: 18-48 mm/1 h.

Pregnant: 2nd half of pregnancy: 30-70 mm/1 h.
ESR Normal Ranges in Pregnancy
Gestational Age Normal ESR Range
1st half of pregnancy 18-48 mm/1 hour
2nd half of pregnancy 30-70 mm/1 hour

Gestational Age Normal ESR Range

1st trimester of pregnancy 4-57 mm/1 hour
2nd trimester of pregnancy 7-47 mm/1 hour
3rd trimester of pregnancy 13-70 mm/1 hour

How to correct ESR in pregnancy ???

Factors affect ESR result
• Conditions falsely decreasing ESR value:
• RBC shape: Sickle cell and spherocytes.
• Plasma factors: Hypofibrinogenemia.
• Polycythemia.
• Others: Hyperglycemia, Lipidemia, Hyperalbuminemia.

• Conditions falsely increasing ESR value:

• Pregnancy (Hypoalbuminemia). • Time of the test.
• Anemia (Dilution factor). • Anticoagulant volume.
• Temperature. • Tube factor: Dimensions.
• Mechanical factors (Standing angel). • Clotted blood sample.
• Vibration. • Air bubbles.
No Corrections, invalid result ….. Repeat
• Mechanical Influences: A 3o inclination can increase the ESR by 30%.
• Vibration: Increased the ESR-Invalid result.
• Air bubbles: Invalid result.
• Clotted blood: Invalid result.
• More time > 60 minutes: Invalid result.
• Dilution factor: invalid result.
How to Report ESR invalid result:
• ESR: The test result is invalid due to the presence of air bubbles in the tube. Please
repeat the test with a new sample.
• ESR: The patient has polycythemia, which may falsely decrease the ESR value.
Temperature correction
• Suitable temperature: 20 – 25 C°.
• First, Control your laboratory temperature.
ESR correction in anemia state

Measured ESR = 16 mm/1st hr.

Patient Hct = 26%.
Corrected Hct = 60 mm/1st hr.
What is the effect of Anticoagulants on ESR?
• Sodium citrate and EDTA do not affect the ESR.
• Sodium or potassium oxalate shrinks the RBCs.
• Heparin shrinks the RBCs and increases false ESR value.
• EDTA is considered one of the anticoagulant choices.

Modification with EDTA:

• 2.0 mL of EWB is used as an anticoagulant with 0.5 mL of 3.8% sodium citrate.
• 2.0 mL of EWB is used as an anticoagulant with 0.5 mL of 0.85 normal saline.

Automated machines and hematology analyzers were used by EDTA WB for ESR
Refrigerated specimens
• Test should be performed within 2 hours of sample collection.
• Otherwise, refrigerate for up to 24 hours (2-8 C).
• Must come to room temperature for 30 minutes before testing

Cold agglutinins
• Cold agglutinins can cause a falsely elevated ESR.
• Worm the specimen and use the rapid ESR method.
How to report ESR result in high buffy coat

• ESR value is the separated line

between plasma and RBC.
• Report note: The elevated buffy coat
observed may affect sedimentation.
Clinical correlation and further
hematological evaluation are
recommended.
 ESR Measurement in the 2nd hour
• Standard ESR measurement is in the first hour.
• In most cases, the first-hour ESR is sufficient for clinical interpretation.
• Any significant changes in the second hour could indicate unusual conditions
that slow down or prolong RBC sedimentation.
• Measuring ESR in the second hour:
• Consistency Check: when there is a discrepancy in the first-hour ESR.
• Hyperviscosity or Polycythemia.
• Reporting the ESR results in the second hour:
• ESR (1st hour): 32 mm/h, ESR (2nd hour): 15 mm/h.
• ESR (1st hour): 32 mm/h, ESR (2nd hour): 47 mm/2nd hour.
• Normal Range for ESR in the second hour:
• Male < 35 mm, Female < 45 mm/2nd hour.
Trisodium citrate 3.8% vs. 3.2%
• Trisodium citrate 3.8%:
• Prepared from 3.8 grams of trisodium citrate per 100 mL
of solution.
• Used for tests like the ESR in a 1:4 blood-to-anticoagulant
ratio.

• Trisodium citrate 3.2%:

• Prepared from 3.2 grams of trisodium citrate per 100 mL
of solution.
• Used in a 1:9 blood-to-anticoagulant ratio for coagulation
studies (PT, APTT).
• Used in automated ESR systems.
What are the Advantages of ESR?
• Used as an initial screening tool. ‫الفحص الطبي الشامل‬
• Advised in occult diseases.
• If ESR increases, the patient needs a thorough workup.
(ESR >100 mm /hour c/w a 90% predictive value of serious diseases)
✓ Rheumatoid Arthritis. ✓ Malignancy, particularly myeloma.
✓ Renal Disease. ✓ Infection.
✓ Sarcoidosis. ✓ Collagen vascular disease.

• Follow-up and monitoring of many diseases.

• ESR correlated with disease severity.
• Support the diagnosis.
• Inexpensive and easy to perform.
What are the Disadvantages of ESR?
• It is a nonspecific test (not for diagnosis).

• Sometimes, it is not elevated in the active disease.

• Increased by other factors like pregnancy and anemia.

• Affected by fibrinogen and globulin concentration.

• Serum cholesterol level may affect the value.

• Sickle cells fail to form rouleaux formation.

 ESR vs. CRP
Clinical Parameters ESR CRP
Sensitivity Less sensitive More sensitive

Pathophysiology (etiology) Fibrinogen level goes up in the serum, Dead and dying cells release chemical factors which
which causes RBCs to clump stimulate the liver to produce CRP

Increase in the level with No relation to antibody CRP Increases before the increase in the antibody
respect to antibody level

Response to inflammation Late response 1. Early response

2. Appear within 24 to 48 hours
3. The peak level is 48 hours
4. Negative in 7 days

After the inflammation Take more time Disappears early

Acute myocardial infarction No relation 1. Increased

2. Correlate with CK-MB
3. Remains elevated for at least 3 months after AMI
ESR & CRP results interpretation
High ESR / Normal CRP Normal ESR / High CRP
• Systemic lupus erythematosus • Urinary tract infections
• Bone and joint infections • GI infections
• Ischemic stroke • Lung infections
• Waldenstrom's macroglobulinemia • Bloodstream infections
• Multiple myeloma • Myocardial infarction
• IgG4-related disease • Venous thromboembolic disease
• Chronic kidney disease • Rheumatoid arthritis
• Low serum albumin • Low serum albumin
CRP
• Qualitative CRP.
• Semi-quantitative CRP.
• Quantitative CRP.
• High sensitive CRP.

Hs-CRP
Risk based on Hs-CRP levels:
• Low risk: <1.0 mg/L
• Moderate risk: 1.0–3.0 mg/L
• High risk: >3.0 mg/L
Automated ESR Systems
• More accuracy, reliability, and efficiency over the traditional methods:
• Uniform temperature, tube size, and angle of sedimentation.
• Eliminating variability from manual handling.
• Optical or Infrared sensor detector at various time intervals.
• Standardized method, which reduced operator error and human error.
• Faster result: within 20–30 minutes or less.
• Small sample volume: microliters of blood.
• Multiple samples

Types of Automated ESR Systems: Limitation of automated systems:

1. Capillary Photometric Method. 1. Cost.
2. Optical Detection Method. 2. False results: polycythemia & hemolysis.
3. Centrifugation-Based Method. 3. Need specific calibration.
Capillary Photometric Method
• Blood is drawn into small capillary
tubes, and the rate of red blood cell
sedimentation is measured
photometrically.
• Light is passed through the blood
sample, and sensors detect changes
in light transmission as the red blood
cells settle at the bottom.
• Results within 10–30 minutes.
• Example Systems: Alifax ESR
analyzers
Optical Detection Method
• Blood is placed in specialized ESR tubes
inside the analyzer, and optical sensors
monitor the descent of red blood cells
over time.
• The optical sensors track changes in
blood opacity or turbidity, which
correlates with the ESR.
• High accuracy, minimal operator
involvement, and ability to run multiple
samples simultaneously.
• Example Systems: Diesse VES-Matic
series.
Centrifugation-Based Method
• The sample is centrifuged to accelerate the
sedimentation of red blood cells.
• The analyzer then calculates the ESR based
on the amount of sedimentation after
centrifugation.
• Faster ESR determination (as little as 5–10
minutes).
• Example Systems: Zeta Sedimentation Ratio
(ZSR) method, though it is less commonly
used today.
Hematology analyzer with ESR
Mindray, BC-700/BC-7200.
• The device uses advanced
technology to automatically
determine the ESR by
monitoring the settling rate
of erythrocytes in a blood
sample. It may use
automated algorithms to
provide accurate and
consistent ESR readings.
• Result time: 1.5 minutes.
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