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{{Infobox diagnostic
| name       = Erythrocyte sedimentation rate
| image      = StaRRsed pipet array.jpg
| caption    = Westergren pipet array on StaRRsed automated ESR analyzer
| ICD10      =
| ICD9       =
| MeshID     =
| LOINC      =
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}}
The '''erythrocyte sedimentation rate''' (ESR), also called a '''sedimentation rate''' or '''Westergren ESR''', is the rate at which [[red blood cells]] sediment in a period of one hour. It is a common [[hematology]] test, and is a non-specific measure of [[inflammation]].
To perform the test, anticoagulated [[blood]] was traditionally placed in an upright tube, known as a Westergren tube, and the rate at which the [[red blood cell]]s fall was measured and reported in mm/h.

Since the introduction of [[automated analyser|automated analyzers]] into the clinical laboratory, the ESR test has been automatically performed.

The ESR is governed by the balance between pro-sedimentation factors, mainly [[fibrinogen]], and those factors resisting sedimentation, namely the negative charge of the erythrocytes ([[zeta potential]]).  When an inflammatory process is present, the high proportion of fibrinogen in the blood causes red blood cells to stick to each other. The red cells form stacks called '[[rouleaux]],' which settle faster. Rouleaux formation can also occur in association with some lymphoproliferative disorders in which one or more [[immunoglobulins]] are secreted in high amounts. Rouleaux formation can, however, be a normal physiological finding in horses, cats, and pigs.

The ESR is increased by any cause or focus of inflammation. The ESR is increased in [[pregnancy]], inflammation, anemia or [[rheumatoid arthritis]], and decreased in [[polycythemia]], [[Sickle-cell disease|sickle cell anemia]], [[hereditary spherocytosis]], and [[Heart failure|congestive heart failure]]. It may be increased in kidney cancer. The basal ESR is slightly higher in females.<ref name=MedlinePlus>{{cite web|title=ESR|url=http://www.nlm.nih.gov/medlineplus/ency/article/003638.htm|publisher=MedlinePlus: U.S. National Library of Medicine & National Institutes of Health|accessdate=8 July 2013}}</ref>

==History==
This test was invented in 1897 by the Polish doctor [[Edmund Biernacki]].<ref>{{WhoNamedIt2|doctor|2783|Edmund Faustyn Biernacki}} and eponymously named {{WhoNamedIt|synd|3352|Biernacki's test}}</ref> In some parts of the world the test continues to be referred to as ''Biernacki's Reaction''  (Polish abbreviation: OB = ''Odczyn Biernackiego''.) In 1918 the Swedish pathologist [[Robert Sanno Fåhræus]] declared the same and, along with [[Alf Vilhelm Albertsson Westergren]], are eponymously remembered for the Fåhræus-Westergren test (abbreviated as FW test; in the UK, usually termed Westergren test),<ref>{{WhoNamedIt2|doctor|2788|Robert (Robin) Sanno Fåhræus}} and {{WhoNamedIt2|doctor|2791|Alf Vilhelm Albertsson Westergren}} who are eponymously named for the {{WhoNamedIt|synd|3359|Fåhræus-Westergren test (aka Westergren test)}}</ref> which uses  sodium citrate-anti-coagulated specimens.<ref name="pmid8463411">{{cite journal |author=International Council for Standardization in Haematology (Expert Panel on Blood Rheology) |title=ICSH recommendations for measurement of erythrocyte sedimentation rate. International Council for Standardization in Haematology (Expert Panel on Blood Rheology)  |journal=J. Clin. Pathol. |volume=46 |issue=3 |pages=198–203 |year=1993 |pmid=8463411 |doi= 10.1136/jcp.46.3.198 |pmc=501169}}</ref>

==Uses==

===Diagnosis===
It can sometimes be useful in diagnosing some diseases, such as [[multiple myeloma]], [[temporal arteritis]], [[polymyalgia rheumatica]], various auto-immune diseases, [[systemic lupus erythematosus]], [[rheumatoid arthritis]], inflammatory bowel disease<ref>{{cite journal|last=Liu|first=S|coauthors=Ren, J; Xia, Q; Wu, X; Han, G; Ren, H; Yan, D; Wang, G; Gu, G; Li, J|title=Preliminary Case-control Study to Evaluate Diagnostic Values of C-Reactive Protein and Erythrocyte Sedimentation Rate in Differentiating Active Crohn's Disease From Intestinal Lymphoma, Intestinal Tuberculosis and Behcet's Syndrome.|journal=The American journal of the medical sciences|date=May 17, 2013|pmid=23689052}}</ref> and chronic kidney diseases.  In many of these cases, the ESR may exceed 100&nbsp;mm/hour.<ref>{{cite web |title=Sedimentation Rate |url=http://www.webmd.com/a-to-z-guides/sedimentation-rate |date=2006-06-16 |publisher=WebMD |accessdate=2008-03-01}}</ref>

It is commonly used for a differential diagnosis for [[Kawasaki's disease]] and it may be increased in some chronic infective conditions like [[tuberculosis]] and infective [[endocarditis]].

Stages in erythrocyte sedimentation:

There are 3 stages in erythrocyte sedimentation 
1) Stage 1  : Rouleaux formation - First 10 minutes 
2) Stage 2  : Stage of sedimentation or settling - 40 mins 
3) Stage 3  : Stage of packin - 10 minutes , sedimentation slows and cells start to pack at the bottom of the tube

===Disease severity===
It is a component of the [[PCDAI]] (Pediatric Crohn's Disease Activity Index), an index for assessment of severity of inflammatory bowel disease in children.

===Monitoring response to therapy===
The clinical usefulness of ESR is limited to monitoring the response to therapy in certain inflammatory diseases such as temporal arteritis, polymyalgia rheumatica and rheumatoid arthritis. It can also be used as a crude measure of response in [[Hodgkin's lymphoma]]. Additionally, ESR levels are used to define one of the several possible adverse prognostic factors in the staging of Hodgkin's lymphoma.

==Normal values==
''Note: mm/hr. = millimeters per hour.''

Westergren's original normal values (men 3mm and women 7mm)<ref name="pmid13455726">{{cite journal |author=Westergren A |title=Diagnostic tests:  the erythrocyte sedimentation rate range and limitations of the technique |journal=Triangle |volume=3 |issue=1 |pages=20–5 |year=1957 |pmid=13455726 |doi=}}</ref> made no allowance for a person's age and in 1967 it was confirmed that ESR values tend to rise with age and to be generally higher in women.<ref name="pmid6020854">{{cite journal |author=Böttiger LE, Svedberg CA |title=Normal erythrocyte sedimentation rate and age |journal=Br Med J |volume=2 |issue=5544 |pages=85–7 |year=1967 |pmid=6020854 |doi= 10.1136/bmj.2.5544.85|pmc=1841240}}</ref>
Values are increased in states of anemia,<ref name="pmid9059375">{{cite journal |author=Kanfer EJ, Nicol BA |title=Haemoglobin concentration and erythrocyte sedimentation rate in primary care patients |journal=Journal of the Royal Society of Medicine |volume=90 |issue=1 |pages=16–8 |year=1997 |pmid=9059375 |doi= |url= |pmc=1296109 |format=Scanned & PDF}}</ref> and in black populations.<ref name="pmid8426384">{{cite journal |author=Gillum RF |title=A racial difference in erythrocyte sedimentation |journal=Journal of the National Medical Association |volume=85 |issue=1 |pages=47–50 |year=1993 |pmid=8426384 |doi= |pmc=2571720}}</ref>

===Adults===
The widely used<ref>{{GPnotebook|389349443|Reference range (ESR)}}</ref> rule for calculating normal maximum ESR values in adults (98% confidence limit) is given by a formula devised in 1983:<ref name="pmid6402065">{{cite journal |author=Miller A, Green M, Robinson D |title=Simple rule for calculating normal erythrocyte sedimentation rate |journal=Br Med J (Clin Res Ed) |volume=286 |issue=6361 |pages=266 |year=1983 |pmid=6402065 |doi= 10.1136/bmj.286.6361.266|pmc=1546487}}</ref>
:<math>{\rm ESR}\ (mm/hr) \le \frac {{\rm Age}\ ({\it in\ years}) + 10\ ({\it if\ female})}{2}</math>

This formula is no longer credited. Other studies show only a small dependence of ESR on age and much lower values, as seen in the following:

ESR reference ranges from a large 1996 study of 3,910 healthy adults:<ref name="pmid8862121">{{cite journal |author=Wetteland P, Røger M, Solberg HE, Iversen OH |title=Population-based erythrocyte sedimentation rates in 3910 subjectively healthy Norwegian adults. A statistical study based on men and women from the Oslo area |journal=J. Intern. Med. |volume=240 |issue=3 |pages=125–31 |year=1996 |pmid=8862121 |doi=10.1046/j.1365-2796.1996.30295851000.x}} - listing  upper reference levels expected to be exceeded only by chance in 5% of subjects</ref>
{| style="text-align:center" border="1" cellpadding="2" width="300"
|-
!   Age
! 20 || 55 || 90
|-
!      Men—5% exceed
| 12 || 14 || 32
|-
!    Women—5% exceed
| 18 || 21 || 23
|}

===Children===
Normal values of ESR have been quoted as 1<ref name="pmid1168702">{{cite journal |author=Adler SM, Denton RL |title=The erythrocyte sedimentation rate in the newborn period |journal=J. Pediatr. |volume=86 |issue=6 |pages=942–8 |year=1975 |pmid=1168702 |doi=10.1016/S0022-3476(75)80233-2}}</ref> to 2<ref name="pmid6937959">{{cite journal |author=Ibsen KK, Nielsen M, Prag J, ''et al.'' |title=The value of the micromethod erythrocyte sedimentation rate in the diagnosis of infections in newborns |journal=Scand J Infect Dis Suppl |volume=Suppl 23 |issue= |pages=143–5 |year=1980 |pmid=6937959 |doi=}}</ref> mm/hr at birth, rising to 4&nbsp;mm/hr 8 days after delivery,<ref name="pmid6937959" /> and then to 17&nbsp;mm/hr by day 14.<ref name="pmid1168702" />

Typical normal ranges quoted are:<ref>{{MedlinePlusEncyclopedia|003638|ESR}}</ref>
*Newborn: 0 to 2&nbsp;mm/hr
*Neonatal to puberty: 3 to 13&nbsp;mm/hr, but other laboratories place an upper limit of 20.<ref name="pmid17545378">{{cite journal|last=Mack|first=D. R.|coauthors=Langton, C.; Markowitz, J.; LeLeiko, N.; Griffiths, A.; Bousvaros, A.; Evans, J.; Kugathasan, S.; Otley, A.; Pfefferkorn, M.; Rosh, J.; Mezoff, A.; Moyer, S.; Oliva-Hemker, M.; Rothbaum, R.; Wyllie, R.; delRosario, J. F.; Keljo, D.; Lerer, T.; Hyams, J.|title=Laboratory Values for Children With Newly Diagnosed Inflammatory Bowel Disease|journal=Pediatrics|date=1 June 2007|volume=119|issue=6|pages=1113–1119|doi=10.1542/peds.2006-1865|pmid=17545378}} - as commented on at<br/>* {{cite web |author=Bauchner H|title=Lab Screening in Children with Suspected Inflammatory Bowel Disease |url=http://pediatrics.jwatch.org/cgi/content/full/2007/613/2 |date=2007-06-13 |publisher=Journal Watch Pediatrics and Adolescent Medicine |accessdate=2008-03-01}}</ref>

==Relation to C-reactive protein==
[[C-reactive protein]] is an [[acute phase protein]] produced by the liver during an inflammatory reaction. Since C-reactive protein levels in the blood rise more quickly after the inflammatory or infective process begins, ESR is often replaced with C-reactive protein measurement. There are specific drawbacks, however: for example, both tests for ESR and CRP were found to be independently associated with a diagnosis of [[acute maxillary sinusitis]]<ref name="sinusitis">{{cite journal |author=Jens Georg Hansen, Henrik Schmidt, Jorn Rosborg,  Elisabeth Lund |title=Predicting acute maxillary sinusitis in a general practice population |journal=BMJ |volume=311 |pages=233–236 |date=22 July 1995|url=http://www.bmj.com/cgi/content/full/311/6999/233 |pmid=7627042 |issue=6999 |pmc=2550286 }}</ref>  so in some cases the combination of the two measurements may improve diagnostic sensitivity and specificity.
Several studies investigated the differential diagnostic values of ESR and CRP in inflammatory disease, and concluded ESR is a potential meaningful biomarker for disease differentiation.<ref>{{cite journal|last=Liu|first=S|coauthors=Ren, J; Xia, Q; Wu, X; Han, G; Ren, H; Yan, D; Wang, G; Gu, G; Li, J|title=Preliminary Case-control Study to Evaluate Diagnostic Values of C-Reactive Protein and Erythrocyte Sedimentation Rate in Differentiating Active Crohn's Disease From Intestinal Lymphoma, Intestinal Tuberculosis and Behcet's Syndrome.|journal=The American journal of the medical sciences|date=May 17, 2013|pmid=23689052}}</ref>

==References==
{{Reflist|2}}

==External links==
* [http://www.mediscuss.org/erythrocyte-sedimentation-rate-77.html Mediscuss on ESR]
* [http://www.aafp.org/afp/991001ap/1443.html ''American Family Physician'' article on ESR]
* [http://labtestsonline.org/understanding/analytes/esr/tab/test ESR] at Lab Tests Online

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[[Category:Blood tests]]
[[Category:Polish inventions]]

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