ERYTHROCYTE SEDIMENTATION RATE (ESR)

Uleng Bahrun

30/06/2022
 OUTLINE
1 DEFINED ESR

2 FACTORS AFFECTING ESR

3 PHASSES IN ESR

4 METHODS

5 THE CLINICAL SIGNIFICANCE OF ESR

ERYTROCYTE SEDIMENTATION RATE (ESR)

Measure of the degree of settling of erytrocyte

in plasma in an anticoagulated whole blood
specimen during a specified period of time.
Reportedly as mm/hr

Easy to perform and ineexpensive

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ERYTROCYTE SEDIMENTATION RATE (ESR)
Detects and monitors inflammation
(Rheumatoid Arthritis, Infection, Malignancies)

Non-specific measuremennt
• Not recommended for screening inflammatory conditions (asymptomatic) 
low in specificity & sensitivity

Definitive diagnosis  Temporal arteritis and Polymyalgia rheumatica

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 ESR and Inflammation Mechanism

Fibrinogen decreased negative charge in erythrocytes  rouleaux formation  increased ESR

1. Dacie and Lewis Practical Haematology 11th Ed
2. 5
Corrigan, T., et al. (2021) Changes in the Physical and Mechanical Properties of Human Blood with Sustained Prophylactic Use of Acetylsalicylic Acid (Aspirin)—A Rheological Study. Open Journal of Fluid Dynamics,
11, 167-176. https://doi.org/10.4236/ojfd.2021.114010
FACTORS AFFECTING ESR
• RBC
• Size and mass
• Shape
• Plasma composition
• Mechanical / technical factors

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 First factor: Red Blood Cell
RBC – size and mass
Larger particle = faster fall
• Macrocytes 
increased sedimentation
• Microcytes  slower
sedimentation Normal RBC 
negatively charged
 repel each Abnormal RBC
other • Decrease negative charge  cause
rouleaux formation
• Rouleaux = larger mass = increase
sedimentation
• Agglutination = increased cell mass
= increase sedimentation
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 First factor: Red Blood Cell CONT..

RBC - shape RBC - population

Anisocytosis and • Anemia  increased
Poikilocytosis  sedimentation
decresed sedimentation
• Polycythemia 
• Sickle cells and decreased/generally
spherocytes normal ESR

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Second factor: Plasma Composition
Acute Phase Reactants Plasma viscocity Cholesterol

• Fibrinogen • Accelerates
• More viscous 
• 𝛼 − 1 𝑔𝑙𝑜𝑏𝑢𝑙𝑖𝑛 Increased ESR
slower ESR
• 𝛽 − 2 𝑔𝑙𝑜𝑏𝑢𝑙𝑖𝑛 sedimentation
• Less viscous 
• 𝛾 − 𝑔𝑙𝑜𝑏𝑢𝑙𝑖𝑛
faster ESR
• *albumin and lectin
 decrease

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Third factor: Mechanical/Technical Factors

ESR tube posisition  3 degree tilt  cause ESR incr 30%

Avoid vibrations, draft, sunlight  increased ESR
Temperature is directly propostopnal to sedimentation  ideal
temp 22-27 oC (room temperature)  the hotter room
temperation  faster ESR
Tube diameter  narrower bore = lower sedimentation ; wider
bore = faster sedimentation
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 Third factor: Mechanical/Technical
Factors CONT…

Bubbles  faster ESR

Anticoagulant  excess = slower ESR

Age specimen  > 2 hours = slower ESR

Time of Reading results  before 1 hour = lower reading

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PHASES IN ESR

Final
Settling
Decantatio
Phase
n Phase

Lag
phase

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 • First 10 minutes
1. Lag Phase • Initial rouleaux formation occurs
• Little sedimentation
Rouleaux formation

• Next 40 minutes
2.Decantation
Phase • Period of more rapid settling
• Constant RBC sedimentation

• Last 10 minutes
3. Final settling
Phase
• Slow RBC sedimentation
• Final settling/Packing

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Methods of ESR Determination
• Westergren Method
• Modified Westergren Method
• Wintrobe Method
• Microsedimentation (Landau) method
• ZETA sedimentation ratio (ZSR)
• Automatic method
• Westergren method for ESR estimation is widely used method -->
Recomendation method by International Council for Standardization of
Hematology (ICHS) (1973)
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Westergren Method
Westergren Tube
• Long tube (30cm long)
• Open on both ends
• Bore is 2.5 mm in diameter
30 cm • Calibration up to 200 mm
• Holds 1 mL of blood
Read after 1 hour and 2 hours
• Most sensitive method for serial study

Anticoagulant: 3.8% sodium citrate

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Modified Westergren Method
Westergren Tube
• same tube is used
anticoagulant
• EDTA
Read
• After 1 hour only
Dilue
• 0.85% Sodium Chloride or 3.8% Sodium Citrate
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Wintrobe Method

Use the left

Wintrobe tube Anticoagulant
side
• Read side (0- • Double
100 from top oxalate or
to bottom EDTA

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Microsedimentation Method

Referred to as mESR

Heparanized micro hematocrit capillary tube

Uses 0.2 mL blood

Uses 0.2 mL blood

For pediatric patients

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ZETA Sedimentation Ratio

Spins capillary tubes in Read like a micro Not affected by

Uses Zetafuge a vertical position in
four 45 second cycles haematocrit anemia
• No longer • Sedimentation • Referred to as • Easier to
produced in three zetacrit interpret
minutes • Hematocrit/zet
acrit = zeta
sedimentation
ratio

 ZETAFUGE

Bull, Brian S.; Brailsford, J. Douglas (1972). The Zeta Sedimentation Ratio. Blood, 40(4), 550–
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559. doi:10.1182/blood.v40.4.550.550
19
Reference Range

Source: Dacie and Lewis Practical Haematology 11th Ed

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 Represents a non specific response to tissue
damage and inflammation

Denotes the presence of disease but not its severity

SIGNIFICANCE
OF ESR
Reflects changes in plasma proteins

Used to follow the progress of certain disease 

Tuberculosis and Rheumatoid Arthritis

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Interpretation
INCREASE Plasma cell myeloma, anemia, old age

(SEEN IN) Pregnancy – after 3rd month

Acute and chronic infections
Rheumatoid Arthritis
Myocardial Infarction
Nephrosis
Menstruation
Macroglobulinemia

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Aaron J. Calderon, MDa,b,*, Mark H. Wener, Hosp Med Clin 1 (2012) e313–e337 doi:10.1016/j.ehmc.2012.02.002 2211-5943/12/$
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Interpretation
NORMAL/ Polycythemia
DECREASE
Congestive Heart failure
(SEEN IN)
Hypofibrinogenemia
RBC abnormalities
Sickle Cell Anemia
heredity Sperocytosis
Hemoglobin CC Disease
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Aaron J. Calderon, MDa,b,*, Mark H. Wener, Hosp Med Clin 1 (2012) e313–e337 doi:10.1016/j.ehmc.2012.02.002 2211-5943/12/$
23
ESR versus CRP (difference between Erythrocytes sedimentation rate vs C-reactive proteins)

Aaron J. Calderon, MDa,b,*, Mark H.

Wener, Hosp Med Clin 1 (2012)
e313–e337
doi:10.1016/j.ehmc.2012.02.002
2211-5943/12/$

24
Changes in CRP and ESR levels after stimulation

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Aaron J. Calderon, MDa,b,*, Mark H. Wener, Hosp Med Clin 1 (2012) e313–e337 doi:10.1016/j.ehmc.2012.02.002 2211-5943/12/$
 BritishJournalofGeneralPractice,July2019

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 BritishJournalofGeneralPractice,July2019

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 Conclusions: Low ESR/high CRP at diagnosis could not only estimate the simultaneous high
BVAS but also predict all-cause mortality during follow-up in AAV patients.

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 ESR and CRP both play an important role in clinical practice. In certain
disease states, one may be a more favorable tool to use over the other. It
is important to take note of the situations during which it is advised to
obtain both, and those during which it would be redundant to do so.
Most importantly, one must never forget that these markers are useful
only if they are used as adjuncts to clinical history and physical exam.

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 ESR and CRP in Schizophrenia

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TAKE HOME MESSAGE
• ESR is a nonspecific test, but this is one of the best tests to
find any kind of abnormality in the body.
• Whenever you find raised ESR, never ignore it but have a
thorough workup of the patients.
• It definitely shows some underlying disease.
• Using ESR and CRP simultaneously increase the sensitivity.

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THANK YOU

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