1. What is ESR? Enumerate the factors that affect the test.

The erythrocyte sedimentation rate (ESR) is ordered with other tests to detect and monitor the course of
inflammatory conditions such as, rheumatoid arthritis, infections, or certain malignancies. It is also useful in the
diagnosis of temporal arteritis and polymyalgia rheumatica. The ESR, however, is not a specific test for
inflammatory diseases and is elevated in many other conditions such as plasma cell myeloma, pregnancy,
anemia, and older age. It is also prone to technical errors that can falsely elevate or decrease the sedimentation
rate. Because of its low specificity and sensitivity, the ESR is not recommended as a screening test to detect
inflammatory conditions in asymptomatic individuals. Other tests for inflammation, such as the C-reactive
protein level, may be a more predictable and reliable alternative to monitor inflammation.
Principle
When anticoagulated blood is allowed to stand at room temperature undisturbed for a period of time, the red
blood cells settle toward the bottom of the tube. The ESR is the distance in millimeters that the red blood cells
fall in 1 hour. The ESR is affected by red blood cell, plasma, and mechanical and technical factors. Red blood
cells have a net negative surface charge and tend to repel one another. The repulsive forces are partially or
totally counteracted if there are increased quantities of positively charged plasma proteins. Under these
conditions the red blood cells settle more rapidly as a result of the formation of rouleaux (stacking of red blood
cells). Examples of macromolecules that can produce this reaction are fibrinogen, b-globulins, and pathologic
immunoglobulins. Normal red blood cells have a relatively small mass and settle slowly. Certain diseases can
cause rouleaux formation, in which the plasma fibrinogen and globulins are altered. This alteration changes the
red blood cell surface, which leads to stacking of the red blood cells, increased red blood cell mass, and a more
rapid ESR. The ESR is directly proportional to the red blood cell mass and inversely proportional to plasma
viscosity. Several methods, both manual and automated, are available for measuring the ESR. Only the most
commonly used methods are discussed here.
ESR (Erythrocyte Sedimentation Rate)
This test determines the rate at which erythrocytes fall to the bottom of a vertical tube of anticoagulated
blood within a specific period. The rate of sedimentation is determined largely by the relative density
of the red blood cells with respect to the plasma.
Stages in ESR:
o In the initial 10 minutes, there is little sedimentation as rouleaux form.
o For about 40 minutes, settling occurs at a constant rate.
o Sedimentation slows in the final 10 minutes as cells pack at the bottom of the tube.
Uses of ESR:
o As an aid in detecting inflammatory process,
o As a monitor of disease course or activity, and
o As a screen for occult inflammatory or neoplastic conditions.
Factors Affecting ESR
Plasma Factors
o Fibrinogen concentration, globulin, particularly gamma globulin concentrations, cholesterol
hyperfibrinogenemia and hyperglobulinemia.
o Albumin and lecithin retard sedimentation, and cholesterol accelerate ESR.
Red Cell Factors
o Increased ESR: Anemia, red cell surface area microcytes sediment more slowly than
macrocytes, rouleaux decreased surface area.
In pregnancy the elevated ESR returns to normal by the third or fourth week
postpartum.

Sedimentation rates of greater than 100 mm/hour are seen in plasma cell dysriasis such
as multiple myeloma, where high immunoglobulin concentrations cause increased
RBC rouleaux. This is also seen in collagen-vascular diseases, malignant diseases and
tuberculosis.
Decreased ESR
Sickle cell anemia
Spherocytosis

CATEGORY
Blood proteins and lipid

INCREASED ESR
Hypercholesterolemia
Hyperfibrinogenemia
Hypergammaglobulinemia
Hypoalbuminemia

DECREASED ESR
Hyperalbuminemia
Hyperglycemia
Hypofibrinogenemia
Hypogammaglobulinemia
Increased bile salts Increased
phospholipids

Red blood cells

Anemia
Macrocytosis

White blood cells

Drugs

Leukemia
Dextran
Heparin
Penicillamine
Procainamide
Theophylline
Vitamin A
Acute heavy metal poisoning
Acute bacterial infections
Collagen vascular diseases
Diabetes mellitus
End-stage renal failure
Gout
Malignancy
Menstruation
Multiple myeloma
Myocardial infarction
Pregnancy
Rheumatic fever
Rheumatoid arthritis
Syphilis
Temporal arteritis
Refrigerated sample not returned to
room temperature
High room temperature
TiltedESR tube

Acanthocytosis
Anisocytosis (marked)
Hemoglobin C
Microcytosis
Polycythemia
Sickle cells
Spherocytosis
Thalassemia
Leukocytosis (marked)
Adrenocorticotropic
hormone
(corticotropin)
Cortisone
Ethambutol
Quinine
Salicylates
Cachexia
Congestive heart failure
Newborn status

Clinical conditions

Specimen handling
Technique

Clotted blood sample

Delay in testing
Bubbles in ESR column
Low room temperature

Vibration

Narrow ESR column diameter

REFERENCE: Hematology: Clinical Principles and Applications by E. Keohane, L. Smith, J.

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