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Erythrocyte Sedimentation Rate
Introduction
The erythrocyte sedimentation rate (sedimentation rate, sed rate, or ESR for short) is a commonly performed hematology test that may indicate and monitor an increase in inflammatory activity within the body caused by one or more conditions such as autoimmune disease, infections, or tumors. The ESR is not specific for any single disease but is used in combination with other tests to determine the presence of increased inflammatory activity. The ESR has long been used as a "sickness indicator" due to its reproducibility and low cost. Over many decades, several methods have evolved to perform the test. However, the reference method for measuring the ESR proposed by the International Committee for Standardization in Haematology (ICSH) is based on the findings described by Westergren a century ago.[1] Newer automated systems using closed blood collection tubes and automatic readers have been introduced into laboratories to decrease the biohazardous risk to operators and decrease the time it takes to perform the ESR.[2]
The Westergren method measures the distance (in millimeters) at which red blood cells in anticoagulated whole blood fall to the bottom of a standardized, upright, elongated tube over one hour due to the influence of gravity. The tube used for the test is called the Westergren tube. Today, these tubes are made of either glass or plastic, with an internal diameter of 2.5 mm and lengths of 190 to 300 mm.[3]
Perhaps the first to notice a change in blood sedimentation due to illness was a British surgeon John Hunter (1728–93), in his posthumous publication, A Treatise on the Blood, Inflammation, and Gun-Shot Wounds.[4] A Polish physician, Edmund Faustyn Biernacki (1866–1911), later refined the clinical use of the ESR near the end of the 19th century.[5] Biernacki detailed his findings in two articles in 1897 (the Gazeta Lekarska in Poland and the Deutsche Medizinische Wochenschrift in Germany) and developed his test for measurements. These findings were not widely propagated in the English-speaking medical communities. Because of his work, the ESR is occasionally called the Biernacki Reaction worldwide.
The applied use of ESR in clinical diagnostics by Biernacki was refined by Dr. Robert Fahraeus in 1918 and Dr. Alf Vilhelm Albertsson Westergren in 1921.[6] Dr. Westergren defined the standard measurement of the ESR that is still in use today.[7] Together, Robert Fahraeus and Alf Vilhelm Albertsson Westergren are often remembered for the test, historically called the Fahraeus-Westergren test (FW test or Westergren test), which uses a standardized tube and sodium citrate anticoagulated blood.[1]
The Westergren method for measuring the ESR proposed by the International Committee for Standardization in Haematology (ICSH) has allowed reproducibility for almost a century. Over time, this same method has established comparable reference values within the same laboratory and even between different facilities across the globe. The ICSH adopted the Westergren method as the gold standard for ESR measurement in 1973.[3] Even after the advent of automated machines used to analyze the ESR, the Westergren method was still confirmed as the gold standard in 2011 by both the ICSH and the Clinical and Laboratory Standards Institute (CLSI).[8]
Pathophysiology
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Pathophysiology
The ESR test measures the rate at which the red blood cells (RBCs), or erythrocytes, in a whole blood sample fall to the bottom of the Westergren tube. This process of "falling" is called sedimentation.[9] The red blood cells typically fall at a faster rate in people with inflammatory conditions such as infections, cancer, or autoimmune disorders. These conditions lead to an increase in the number of proteins in the blood. This increase causes red blood cells to stick together (clump) and settle faster. A group of RBCs clumped together will form a stack (similar to a stack of coins) called a rouleau (pleural, rouleaux).[10] Rouleaux formation is possible because of the particular discoid shape of RBCs. The flat surfaces of the RBCs allow them to make contact with other RBCs and stick together.[11]
Typically, RBCs have negative charges on the outside of the cells, which cause them to repel each other. Many plasma proteins have positive charges and can effectively neutralize the negative surface charges of the RBCs, which allows for the formation of the rouleaux. Therefore, an increase in plasma proteins (present in inflammatory conditions) will propagate an increase in rouleaux formations, which settle more readily than single red blood cells.[12] The settling of the rouleaux aggregates in the Westergren tube occurs at a constant rate. The formation of rouleaux allows the RBCs to settle at a faster rate, thus increasing the ESR. Therefore, the ESR is not the measure of a single marker but a physical process. [13]
Rouleaux formation (and thus the ESR) is affected by the amounts of immunoglobulins and acute phase proteins (prothrombin, plasminogen, fibrinogen, C-reactive protein, alpha-1 antitrypsin, haptoglobin, complement proteins) that are present in several inflammatory conditions.[14] "Acute-phase proteins" (APP) is the name given to a class of approximately 30 distinct, chemically unrelated plasma proteins that are innately regulated in response to infection and inflammation.[15] APPs are produced by the liver and are functionally controlled by the body in response to several forms of tissue damage or insult. These proteins act as inhibitors or mediators of the inflammatory response.[16]
The detection of the first acute phase protein in the 1930s, the C-reactive protein (CRP), occurred during the analysis of the plasma of patients diagnosed with acute pneumococcal pneumonia.[17] The CRP and many other acute-phase proteins may increase during ongoing tissue damage, either acutely or chronically.[18] "Acute phase" is still used to label these proteins that change in concentration during specific disease processes, regardless of chronicity. The fluctuating nature of the acute phase proteins in inflammation leads to the increased "stickiness" of RBCs, the formation of RBC "stacks" (rouleaux formation), and an increase in ESR.[19]
Although many inflammatory illnesses will increase the ESR, other conditions exist that can lower the ESR. These "lowering factors" can exist either as isolated disease processes or in conjunction with other pathologic conditions that raise the ESR, thus giving a "lower than expected" ESR result in light of a serious underlying inflammatory process.[20] Polycythemia (an increased number of red blood cells) will increase blood viscosity and can cause a reduced ESR (reduces the rate at which RBC rouleaux will settle to the bottom of the Westergren tube).[21] Some hemoglobinopathies, such as sickle cell disease, can lower ESR due to the abnormal shape of red blood cells that impairs rouleaux formation. Spherocytosis (the presence of sphere-shaped rather than disc-shaped RBCs) also inhibits rouleaux formation and can decrease the ESR.[22]
Specimen Requirements and Procedure
The Westergren method involves a simple blood draw that should take only a minute or two to obtain.[23] A phlebotomist or other health care professional will obtain the blood sample. The skin directly over a vein is cleaned. Then, a needle is inserted into the vein to collect blood. After collection, the needle is removed, and the puncture site is covered with a dressing to stop any bleeding.[24]
Blood is typically collected in a black top ESR vacuum tube that contains a 3.2% sodium citrate anticoagulant. Whole blood collected in a lavender EDTA tube is also acceptable. The sample must be in its own tube (black or lavender) and cannot be combined with other tests due to the volume required.[25]
The blood sample will be sent to a laboratory. A lab technician will then transfer the anticoagulated whole blood to a vertical test tube (Westergren tube), which is inserted into the vacuum tube. When this sample is allowed to stand in the vertical tube for one hour, the red blood cells will slowly fall (settle) to the bottom due to the influence of gravity. This will leave a clear, straw-colored fluid at the top of the tube. This clear fluid is plasma, the portion of blood that remains after the red blood cells and other cellular components have settled to the bottom of the tube.[8]
The test result will depend on the amount of plasma at the top of the tube, measured after one hour. The result will be reported in millimeters per hour (mm/hr).[26]
Diagnostic Tests
ESR can be measured by various methods, including the Westergren, Wintrobe, micro-ESR, and automated machines.[27] Historically, the Westergren was the most commonly used method of performing the ESR. Technical factors, such as the amount of blood drawn into the tube, vibrations, temperature, time from specimen collection, the addition of proper anticoagulants, and tube orientation, can affect the results. RBC size, shape, and concentration can alter the ESR results. Plasma characteristics also have an impact on the value of the ESR.[28]
The Westergren method has classically been used to measure the ESR based on the distance RBCs settle to the bottom of an elongated tube with a 2.5 cm internal bore. It is graduated downward in millimeters, from 0 to 200, allowing the clear plasma to remain at the top of the tube after the RBCs have settled toward the bottom due to gravitational force after one hour of observation.[8]
Many additional methods have been proposed, including the Linzenmeier method, the Graphic or Cutler method, the Wintrobe-Landsberg method, and the Landau method. Only the Westergren and Wintrobe methods are common today. The Wintrobe method uses tubes only 100 mm long with a smaller bore (thinner tube) than standard Westergren tubes. It is considered less sensitive than Westergren.[29]
Although the Westergren method is commonly used for determining the ESR, it is time-consuming, and there is room for error. In an attempt to find faster and more reliable means of obtaining the ESR, newer methods have evolved.[14] Some methods utilize centrifuge and automated machines and can produce results as quickly as five minutes.[30]
The micro-ESR is a method of obtaining the ESR using capillary tubes and quicker testing times. This method uses four drops of capillary blood drawn via fingerstick, then mixed in a 4:1 ratio on a slide with a 3.8 percent sodium citrate solution. The sample is then drawn into a 7.5-centimeter heparin-free microhematocrit capillary tube.[12] The results are measured at just 20 minutes and then adjusted to predict conventional ESR values from the micro-ESR value. Other automated methods for determining the ESR have become available. One study indicated that fewer labs use the unmodified Westergren technique, and results using automated machines could differ from conventional results by 142%.[31]
Several new automated and semi-automated techniques have become available for determining the ESR; these methods are safer and faster with higher accuracy. The International Council for Standardization in Haematology (ICSH) has reviewed the accuracy and consistency of over a dozen methods. Recommendations have been made for the manufacturers for the validation of new ESR methods.[31] Recent studies indicate that automated measurements of the ESR have high comparability with the Westergren method.[32] Many automated machines do not measure sedimentation but rather calculate a mathematically derived rate based on aggregate measurements in the early stages of RBC clumping (rouleaux formation). It will be up to the manufacturers and healthcare facilities to ensure the new procedures are validated and verified.[27]
Interfering Factors
Technical factors, such as seasonal variations in room temperature, time from specimen collection, tube orientation and inclination, and vibration, can affect the results.[28] A higher room temperature decreases blood viscosity and may increase the ESR.[33] Direct sunlight can increase the ESR. A tilted ESR tube and vibrations may also cause an increase in the ESR value. An angle of three degrees from vertical can increase the ESR by 30 percent. Improper filling of the ESR tube may cause bubble formation and increase the ESR value.[34]
A blood sample allowed to sit too long before starting the test will cause RBC sphering and decrease the ESR value. The test should be run within two hours of collection. A clotted blood sample will inhibit rouleaux formation and decrease the ESR.[35] Using ESR tubes with inconsistent internal boreholes can be sensitive to RBC clumps and may lead to variations in the ESR results. Icteric blood samples (drawn from patients with liver disease) will produce a dark yellow plasma that may be difficult to differentiate from the sedimented RBCs by direct inspection. Likewise, hemolysis (damaged erythrocytes) will cause hemoglobin to leak into the plasma and turn it red, making it difficult to differentiate from the sedimented RBCs.[36]
Results, Reporting, and Critical Findings
As with other tests, the actual reference range used for the ESR should be established by the laboratory performing the test.
The ESR is typically higher in females than males and increases gradually with age.[26][20][37] [26]Normal values for the erythrocyte sedimentation rate (ESR), as obtained using the Westergren method, are as follows:
- Male <50 years old: ≤15 mm/hr
- Female <50 years old: ≤ 20 mm/hr
- Male >50 years old: ≤20 mm/hr
- Female >50 years old: ≤30 mm/hr
- Child: ≤10 mm/hr [38]
Clinical Significance
Several factors may influence the ESR. Females tend to have slightly increased ESRs compared to males.[26] Pregnancy and aging may also increase the ESR. Anemia, RBC abnormalities, technical factors such as tilted ESR tubes, increased specimen temperature, and dilution errors may increase the ESR.[39]
The ESR is neither sensitive nor specific as a general screening test. Because an elevated ESR may occur in multiple clinical settings, it is meaningless as a stand-alone laboratory value. Furthermore, some patients with malignant lesions, serious infections, or significant inflammatory disorders may have normal ESR values.[40] An elevated ESR level should heighten the practitioner's index of suspicion of the potential for underlying illness. These illnesses may include:
- Anemia
- Arteritis
- Infections (including bone and joint)
- Kidney disease
- Low serum albumin
- Systemic lupus erythematosus
- Lymphoma, including lymphoplasmacytic lymphoma
- Multiple myeloma
- Polymyalgia rheumatica
- Red blood cell abnormalities
- Rheumatoid arthritis
- Systemic vasculitis
- Thyroid disease
Any process that elevates fibrinogen levels (e.g., pregnancy, infection, diabetes mellitus, end-stage renal disease, heart disease, malignancy) may also elevate the ESR. An extremely high ESR value (>100 mm/hr) may indicate the presence of infection, multiple myeloma, lymphoplasmacytic lymphoma (Waldenström macroglobulinemia), giant cell (temporal) arteritis, polymyalgia rheumatica, or hypersensitivity vasculitis. One study reported that the average ESR was over 90 mm per hour in patients with temporal arteritis, with values over 30 mm per hour in 99% of the patients.[41] The extremely high elevation of the ESR (>100 mm per hour) is associated with a low false-positive rate for a significant underlying illness.[42] Infection is likely the cause of an extreme elevation, followed by collagen vascular disease and metastatic tumors.[43] In oncology, a high ESR tends to correlate with a poor prognosis for various types of cancers.[44][45]
- An elevated ESR may be an important adjunct in detecting coronary artery disease.[46][47] This is possibly linked to the inflammatory condition of coronary disease.[48]
- There may exist a relationship between the ESR in ischemic stroke and the amount of local brain injury, atherosclerosis, and short-term outcomes.[49][50]
- Polymyalgia rheumatica and giant cell (temporal) arteritis are inflammatory conditions that usually occur in persons older than 50 years.[51][20][51] The ESR is a useful test for diagnosing these illnesses. However, lower ESR levels should not exclude these diagnoses.[52]
- In rheumatoid arthritis, systemic lupus erythematosus, and osteoarthritis, ESR levels are frequently used to help make the diagnosis; the levels may be poorly correlated with the clinical aspects of disease intensity.[53] Some patients with active rheumatoid arthritis and synovial joint inflammation on biopsy will have a normal ESR.[54]
- Periprosthetic joint infection (PJI) is an adverse complication of total hip and knee arthroplasty. ESR has low sensitivity in a suspected PJI, ranging from 42% to 94%.[55]
- An isolated ESR is of variable sensitivity and is not optimal to rule out septic arthritis. However, in combination with an inability to bear weight normally and increased temperature, the ESR may be a helpful test, especially when using a low ESR threshold (>15 mm/hr).[56]
- An elevated ESR may be useful in the diagnosis and follow-up in patients with osteomyelitis. Optimal ESR cutoff levels for the diagnosis are variable.[57][58] In cases of proven osteomyelitis, the ESR may be used to monitor response to therapy or relapse.[59]
- An elevated ESR is associated with metastasis and a worse prognosis in patients with cutaneous malignant melanoma.[60] High ESR has been found to correlate with overall poor prognosis for several cancer types, including breast, prostate, colorectal, Hodgkin lymphoma, and chronic lymphocytic leukemia.[20]
- ESR may be used as an indicator of the presence of invasive bacterial infection in children.[61] The sensitivity of the ESR to detect a bacterial bone or joint infection on admission has been reported at 94% using an ESR cutoff of 20 mm/hr.[62]
Aside from factors that increase ESR, the healthcare team should consider the factors that decrease ESR. This is especially important because circumstances that decrease the ESR may coexist with diagnoses that increase the ESR result, leading to missed diagnoses. Factors that lower the ESR include an increased number of red blood cells (polycythemia), which causes an increase in blood viscosity.[63] Hemoglobinopathies such as sickle cell disease can produce a lower ESR due to an improper shape of red blood cells that impairs stacking.[64]
Regular alcohol use is negatively associated with ESR. Alcohol drinkers of low, moderate, and high quantities of alcohol will show a lower ESR than abstainers and occasional drinkers. Regular physical exercise at moderate and high levels was associated with lower ESR rates than typically expected.[26]
The test must be performed using blood drawn within two hours of testing. In standing blood, erythrocytes tend to become spherical, which impedes rouleaux formation. Anisocytosis and poikilocytosis also interfere with erythrocyte stacking, thus decreasing the ESR.[14]
Certain medications (valproic acid, statins, nonsteroidal anti-inflammatory drugs) may lower the ESR value.[65][66]
Quality Control and Lab Safety
For non-waived tests, laboratory regulations require, at the minimum, analysis of at least two levels of control materials once every 24 hours. Laboratories can assay QC samples more frequently to ensure accurate results. Quality control samples should be assayed after calibration or maintenance of an analyzer to verify the correct method performance. To minimize QC when performing tests for which manufacturers’ recommendations are less than those required by the regulatory agency (such as once per month),[67] the labs can develop an individualized quality control plan (IQCP) that involves performing a risk assessment of potential sources of error in all phases of testing and putting in place a QC plan to reduce the likelihood of errors.[68] Westgard multi-rules are used to evaluate the quality control runs. In case of any rule violation, proper corrective and preventive action should be taken before patient testing.[69]
The laboratory must participate in the external quality control or proficiency testing (PT) program because it is a regulatory requirement published by the Centers for Medicare and Medicaid Services (CMS) in the Clinical Laboratory Improvement Amendments (CLIA) regulations.[70] It is helpful to ensure the accuracy and reliability of the laboratory with regard to other laboratories performing the same or comparable assays. Required participation and scored results are monitored by CMS and voluntary accreditation organizations. The PT plan should be included as an aspect of the quality assessment (QA) plan and the overall quality program of the laboratory.[71]
Consider all specimens, control materials, and calibrator materials as potentially infectious. Exercise the usual precautions required for handling all laboratory reagents. Disposal of all waste material should be in accordance with local guidelines. Wear gloves, a lab coat, and safety glasses when handling human blood specimens. Place all plastic tips, sample cups, and gloves that come into contact with blood in a biohazard waste container.[72] Discard all disposable glassware into sharps waste containers. Protect all work surfaces with disposable absorbent bench top paper, discarded into biohazard waste containers weekly or whenever blood contamination occurs. Wipe all work surfaces weekly.[73]
Enhancing Healthcare Team Outcomes
Individuals with elevated ESR values may not always have a medical condition that requires treatment. A result outside the usual range is not necessarily a cause for concern. Slightly higher levels can occur due to laboratory errors, pregnancy, menstruation, or advancing age. The ESR result may establish the presence of an inflammatory condition within the body, but the test is not specific to any disease process. It must be combined with other modalities to define an underlying ailment. The use of the ESR as a screening test in asymptomatic patients is limited due to the low sensitivity and specificity.
If there exists a suspicion of disease, the ESR may have some value as a “sickness index.” If the level is extremely elevated (>100 mm/hr), an apparent cause is usually present (malignancy, infection, temporal arteritis). If the level is mild to moderately elevated without obvious causes, additional testing may be added in an extensive search for the underlying disease process. There is no evidence to suggest that an elevated ESR not supported by an alarming history, physical, or other modalities should prompt an extensive workup or further invasive procedures.[43][20] Repeating the ESR testing in an asymptomatic patient after several months may be indicated if a patient’s condition is stable. A continuously elevated ESR may prompt a more expansive and expensive search for hidden diseases.
Collaboration amongst the interprofessional team to correctly understand and interpret the ESR results is paramount to guide further diagnostics, therapeutics, and consultations for the overall benefit of the patient.
References
. ICSH recommendations for measurement of erythrocyte sedimentation rate. International Council for Standardization in Haematology (Expert Panel on Blood Rheology). Journal of clinical pathology. 1993 Mar:46(3):198-203 [PubMed PMID: 8463411]
Level 1 (high-level) evidencePlebani M, De Toni S, Sanzari MC, Bernardi D, Stockreiter E. The TEST 1 automated system: a new method for measuring the erythrocyte sedimentation rate. American journal of clinical pathology. 1998 Sep:110(3):334-40 [PubMed PMID: 9728608]
. Reference method for the erythrocyte sedimentation rate (ESR) test on human blood. British journal of haematology. 1973 May:24(5):671-3 [PubMed PMID: 4732536]
Madrenas J, Potter P, Cairns E. Giving credit where credit is due: John Hunter and the discovery of erythrocyte sedimentation rate. Lancet (London, England). 2005 Dec 17:366(9503):2140-1 [PubMed PMID: 16360794]
Amezcua-Guerra LM, Castillo-Martinez D, Bojalil R. The story behind the acute-phase reactants. The Journal of rheumatology. 2010 Feb:37(2):469; author reply 470. doi: 10.3899/jrheum.090991. Epub [PubMed PMID: 20147484]
Level 3 (low-level) evidenceGrzybowski A, Sak J. Edmund Biernacki (1866-1911): Discoverer of the erythrocyte sedimentation rate. On the 100th anniversary of his death. Clinics in dermatology. 2011 Nov-Dec:29(6):697-703 [PubMed PMID: 23293796]
Harrison M. Erythrocyte sedimentation rate and C-reactive protein. Australian prescriber. 2015 Jun:38(3):93-4 [PubMed PMID: 26648629]
Narang V, Grover S, Kang AK, Garg A, Sood N. Comparative Analysis of Erythrocyte Sedimentation Rate Measured by Automated and Manual Methods in Anaemic Patients. Journal of laboratory physicians. 2020 Dec:12(4):239-243. doi: 10.1055/s-0040-1721155. Epub 2020 Dec 30 [PubMed PMID: 33390672]
Level 2 (mid-level) evidencePlebani M, Piva E. Erythrocyte sedimentation rate: use of fresh blood for quality control. American journal of clinical pathology. 2002 Apr:117(4):621-6 [PubMed PMID: 11939738]
Level 2 (mid-level) evidenceAbramson N. Rouleaux formation. Blood. 2006 Jun 1:107(11):4205 [PubMed PMID: 16739263]
Level 3 (low-level) evidenceRiha P, Liao F, Stoltz JF. The effect of rouleaux formation on blood coagulation. Clinical hemorheology and microcirculation. 1997 Jul-Aug:17(4):341-6 [PubMed PMID: 9493903]
Hashemi R, Majidi A, Motamed H, Amini A, Najari F, Tabatabaey A. Erythrocyte Sedimentation Rate Measurement Using as a Rapid Alternative to the Westergren Method. Emergency (Tehran, Iran). 2015 Spring:3(2):50-3 [PubMed PMID: 26495381]
Taneja N. ERYTHROCYTE SEDIMENTATION RATE - IS THERE A NEED FOR A FASTING BLOOD SAMPLE? Medical journal, Armed Forces India. 1997 Jan:53(1):72. doi: 10.1016/S0377-1237(17)30655-X. Epub 2017 Jun 26 [PubMed PMID: 28769445]
Litao MK, Kamat D. Erythrocyte sedimentation rate and C-reactive protein: how best to use them in clinical practice. Pediatric annals. 2014 Oct:43(10):417-20. doi: 10.3928/00904481-20140924-10. Epub [PubMed PMID: 25290132]
Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation. The New England journal of medicine. 1999 Feb 11:340(6):448-54 [PubMed PMID: 9971870]
Cooper EH. Acute phase reactant proteins. Immunology series. 1990:53():521-36 [PubMed PMID: 1713068]
Tillett WS, Francis T. SEROLOGICAL REACTIONS IN PNEUMONIA WITH A NON-PROTEIN SOMATIC FRACTION OF PNEUMOCOCCUS. The Journal of experimental medicine. 1930 Sep 30:52(4):561-71 [PubMed PMID: 19869788]
Volanakis JE. Human C-reactive protein: expression, structure, and function. Molecular immunology. 2001 Aug:38(2-3):189-97 [PubMed PMID: 11532280]
Gewurz H, Mold C, Siegel J, Fiedel B. C-reactive protein and the acute phase response. Advances in internal medicine. 1982:27():345-72 [PubMed PMID: 7041546]
Level 3 (low-level) evidenceBrigden ML. Clinical utility of the erythrocyte sedimentation rate. American family physician. 1999 Oct 1:60(5):1443-50 [PubMed PMID: 10524488]
Brigden M. The erythrocyte sedimentation rate. Still a helpful test when used judiciously. Postgraduate medicine. 1998 May:103(5):257-62, 272-4 [PubMed PMID: 9590999]
Bray C, Bell LN, Liang H, Haykal R, Kaiksow F, Mazza JJ, Yale SH. Erythrocyte Sedimentation Rate and C-reactive Protein Measurements and Their Relevance in Clinical Medicine. WMJ : official publication of the State Medical Society of Wisconsin. 2016 Dec:115(6):317-21 [PubMed PMID: 29094869]
Sikka M, Tandon R, Rusia U, Madan N. Validation of ESR analyzer using Westergren ESR method. Indian journal of pathology & microbiology. 2007 Jul:50(3):634-5 [PubMed PMID: 17883168]
Level 1 (high-level) evidenceHarr KE. Sample Collection. The veterinary clinics of North America. Exotic animal practice. 2018 Sep:21(3):579-592. doi: 10.1016/j.cvex.2018.05.008. Epub [PubMed PMID: 30078449]
Level 3 (low-level) evidenceGiavarina D, Capuzzo S, Cauduro F, Carta M, Soffiati G. Internal quality control for erythrocyte sedimentation rate measured by TEST-1 Analyzer. Clinical laboratory. 2002:48(9-10):459-62 [PubMed PMID: 12389704]
Level 2 (mid-level) evidenceAlende-Castro V, Alonso-Sampedro M, Vazquez-Temprano N, Tuñez C, Rey D, García-Iglesias C, Sopeña B, Gude F, Gonzalez-Quintela A. Factors influencing erythrocyte sedimentation rate in adults: New evidence for an old test. Medicine. 2019 Aug:98(34):e16816. doi: 10.1097/MD.0000000000016816. Epub [PubMed PMID: 31441853]
Mahlangu JN, Davids M. Three-way comparison of methods for the measurement of the erythrocyte sedimentation rate. Journal of clinical laboratory analysis. 2008:22(5):346-52. doi: 10.1002/jcla.20267. Epub [PubMed PMID: 18803269]
Ramsay ES, Lerman MA. How to use the erythrocyte sedimentation rate in paediatrics. Archives of disease in childhood. Education and practice edition. 2015 Feb:100(1):30-6. doi: 10.1136/archdischild-2013-305349. Epub 2014 Sep 9 [PubMed PMID: 25205237]
GILMOUR D, SYKES AJ. Westergren and Wintrobe methods of estimating ESR compared. British medical journal. 1951 Dec 22:2(4746):1496-7 [PubMed PMID: 14886634]
Batlivala SP. Focus on diagnosis: the erythrocyte sedimentation rate and the C-reactive protein test. Pediatrics in review. 2009 Feb:30(2):72-4. doi: 10.1542/pir.30-2-72. Epub [PubMed PMID: 19188303]
Kratz A, Plebani M, Peng M, Lee YK, McCafferty R, Machin SJ, International Council for Standardization in Haematology (ICSH). ICSH recommendations for modified and alternate methods measuring the erythrocyte sedimentation rate. International journal of laboratory hematology. 2017 Oct:39(5):448-457. doi: 10.1111/ijlh.12693. Epub 2017 May 12 [PubMed PMID: 28497537]
Lapić I, Piva E, Spolaore F, Tosato F, Pelloso M, Plebani M. Automated measurement of the erythrocyte sedimentation rate: method validation and comparison. Clinical chemistry and laboratory medicine. 2019 Aug 27:57(9):1364-1373. doi: 10.1515/cclm-2019-0204. Epub [PubMed PMID: 30939112]
Level 1 (high-level) evidenceMANLEY RW. The effect of room temperature on erythrocyte sedimentation rate and its correction. Journal of clinical pathology. 1957 Nov:10(4):354-6 [PubMed PMID: 13481122]
THORSEN G, RICHTER W. The effect of hematocrit, temperature and molecular structure on erythrocyte sedimentation rate in model experiments. Acta medica Scandinavica. 1959 Oct 28:165():173-9 [PubMed PMID: 13838233]
LAWRENCE JS. Sources of error in the erythrocyte sedimentation rate. Annals of the rheumatic diseases. 1953 Sep:12(3):206-11 [PubMed PMID: 13105212]
HIRSCH A. [Studies on the sources of errors in determining the blood sedimentation rate according to Westergren method]. Medizinische Klinik. 1953 Dec 18:48(51):1886-90 [PubMed PMID: 13132376]
Böttiger LE, Svedberg CA. Normal erythrocyte sedimentation rate and age. British medical journal. 1967 Apr 8:2(5544):85-7 [PubMed PMID: 6020854]
Al-Marri MR, Kirkpatrick MB. Erythrocyte sedimentation rate in childhood tuberculosis: is it still worthwhile? The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease. 2000 Mar:4(3):237-9 [PubMed PMID: 10751069]
MARTENSSON EH, HANSEN HA. Studies on factors influencing erythrocyte sedimentation rate. Acta medica Scandinavica. 1953:146(3):164-83 [PubMed PMID: 13091728]
Fincher RM, Page MI. Clinical significance of extreme elevation of the erythrocyte sedimentation rate. Archives of internal medicine. 1986 Aug:146(8):1581-3 [PubMed PMID: 3729639]
Huston KA, Hunder GG, Lie JT, Kennedy RH, Elveback LR. Temporal arteritis: a 25-year epidemiologic, clinical, and pathologic study. Annals of internal medicine. 1978 Feb:88(2):162-7 [PubMed PMID: 626444]
Lluberas-Acosta G, Schumacher HR Jr. Markedly elevated erythrocyte sedimentation rates: consideration of clinical implications in a hospital population. The British journal of clinical practice. 1996 Apr-May:50(3):138-42 [PubMed PMID: 8733332]
Sox HC Jr, Liang MH. The erythrocyte sedimentation rate. Guidelines for rational use. Annals of internal medicine. 1986 Apr:104(4):515-23 [PubMed PMID: 3954279]
Ljungberg B, Grankvist K, Rasmuson T. Serum acute phase reactants and prognosis in renal cell carcinoma. Cancer. 1995 Oct 15:76(8):1435-9 [PubMed PMID: 8620420]
Johansson JE, Sigurdsson T, Holmberg L, Bergström R. Erythrocyte sedimentation rate as a tumor marker in human prostatic cancer. An analysis of prognostic factors in 300 population-based consecutive cases. Cancer. 1992 Sep 15:70(6):1556-63 [PubMed PMID: 1516006]
Level 3 (low-level) evidenceYayan J. Erythrocyte sedimentation rate as a marker for coronary heart disease. Vascular health and risk management. 2012:8():219-23. doi: 10.2147/VHRM.S29284. Epub 2012 Apr 11 [PubMed PMID: 22536077]
Level 2 (mid-level) evidenceFatih Ozlu M, Sen N, Fatih Karakas M, Turak O, Ozcan F, Kanat S, Aras D, Topaloglu S, Cagli K, Timur Selcuk M. Erythrocyte sedimentation rate in acute myocardial infarction as a predictor of poor prognosis and impaired reperfusion. Medicinski glasnik : official publication of the Medical Association of Zenica-Doboj Canton, Bosnia and Herzegovina. 2012 Aug:9(2):189-97 [PubMed PMID: 22926349]
Andresdottir MB, Sigfusson N, Sigvaldason H, Gudnason V. Erythrocyte sedimentation rate, an independent predictor of coronary heart disease in men and women: The Reykjavik Study. American journal of epidemiology. 2003 Nov 1:158(9):844-51 [PubMed PMID: 14585762]
Zaremba J, Skrobański P, Losy J. Acute ischaemic stroke increases the erythrocyte sedimentation rate, which correlates with early brain damage. Folia morphologica. 2004 Nov:63(4):373-6 [PubMed PMID: 15712129]
Singh AS, Atam V, Yathish BE, Das L, Koonwar S. Role of erythrocyte sedimentation rate in ischemic stroke as an inflammatory marker of carotid atherosclerosis. Journal of neurosciences in rural practice. 2014 Jan:5(1):40-5. doi: 10.4103/0976-3147.127870. Epub [PubMed PMID: 24741248]
Epperly TD, Moore KE, Harrover JD. Polymyalgia rheumatica and temporal arthritis. American family physician. 2000 Aug 15:62(4):789-96, 801 [PubMed PMID: 10969858]
Level 3 (low-level) evidenceCheema MR, Ismaeel SM. Temporal arteritis with erythrocyte sedimentation rate {50 mm/h: a clinical reminder. Clinical interventions in aging. 2016:11():185-8. doi: 10.2147/CIA.S40919. Epub 2016 Feb 23 [PubMed PMID: 26966355]
Keenan RT, Swearingen CJ, Yazici Y. Erythrocyte sedimentation rate and C-reactive protein levels are poorly correlated with clinical measures of disease activity in rheumatoid arthritis, systemic lupus erythematosus and osteoarthritis patients. Clinical and experimental rheumatology. 2008 Sep-Oct:26(5):814-9 [PubMed PMID: 19032813]
Level 2 (mid-level) evidenceOrr CK, Najm A, Young F, McGarry T, Biniecka M, Fearon U, Veale DJ. The Utility and Limitations of CRP, ESR and DAS28-CRP in Appraising Disease Activity in Rheumatoid Arthritis. Frontiers in medicine. 2018:5():185. doi: 10.3389/fmed.2018.00185. Epub 2018 Aug 3 [PubMed PMID: 30123796]
Saleh A, George J, Faour M, Klika AK, Higuera CA. Serum biomarkers in periprosthetic joint infections. Bone & joint research. 2018 Jan:7(1):85-93. doi: 10.1302/2046-3758.71.BJR-2017-0323. Epub [PubMed PMID: 29363518]
Hariharan P, Kabrhel C. Sensitivity of erythrocyte sedimentation rate and C-reactive protein for the exclusion of septic arthritis in emergency department patients. The Journal of emergency medicine. 2011 Apr:40(4):428-31. doi: 10.1016/j.jemermed.2010.05.029. Epub 2010 Jul 22 [PubMed PMID: 20655163]
Level 2 (mid-level) evidenceMichail M, Jude E, Liaskos C, Karamagiolis S, Makrilakis K, Dimitroulis D, Michail O, Tentolouris N. The performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis. The international journal of lower extremity wounds. 2013 Jun:12(2):94-9. doi: 10.1177/1534734613486152. Epub 2013 May 9 [PubMed PMID: 23667102]
Lavery LA, Ahn J, Ryan EC, Bhavan K, Oz OK, La Fontaine J, Wukich DK. What are the Optimal Cutoff Values for ESR and CRP to Diagnose Osteomyelitis in Patients with Diabetes-related Foot Infections? Clinical orthopaedics and related research. 2019 Jul:477(7):1594-1602. doi: 10.1097/CORR.0000000000000718. Epub [PubMed PMID: 31268423]
Fritz JM, McDonald JR. Osteomyelitis: approach to diagnosis and treatment. The Physician and sportsmedicine. 2008 Dec:36(1):nihpa116823. doi: 10.3810/psm.2008.12.11. Epub [PubMed PMID: 19652694]
Tas F, Erturk K. Elevated erythrocyte sedimentation rate is associated with metastatic disease and worse survival in patients with cutaneous malignant melanoma. Molecular and clinical oncology. 2017 Dec:7(6):1142-1146. doi: 10.3892/mco.2017.1440. Epub 2017 Oct 4 [PubMed PMID: 29285390]
Stuart J, Whicher JT. Tests for detecting and monitoring the acute phase response. Archives of disease in childhood. 1988 Feb:63(2):115-7 [PubMed PMID: 3126717]
Pääkkönen M, Kallio MJ, Kallio PE, Peltola H. Sensitivity of erythrocyte sedimentation rate and C-reactive protein in childhood bone and joint infections. Clinical orthopaedics and related research. 2010 Mar:468(3):861-6. doi: 10.1007/s11999-009-0936-1. Epub 2009 Jun 17 [PubMed PMID: 19533263]
Damanhouri GA, Jarullah J, Marouf S, Hindawi SI, Mushtaq G, Kamal MA. Clinical biomarkers in sickle cell disease. Saudi journal of biological sciences. 2015 Jan:22(1):24-31. doi: 10.1016/j.sjbs.2014.09.005. Epub 2014 Sep 18 [PubMed PMID: 25561879]
Lawrence C, Fabry ME. Erythrocyte sedimentation rate during steady state and painful crisis in sickle cell anemia. The American journal of medicine. 1986 Nov:81(5):801-8 [PubMed PMID: 3776987]
Nutt JG, Neophytides AN, Lodish JR. Lowered erythrocyte-sedimentation rate with sodium valproate. Lancet (London, England). 1978 Sep 16:2(8090):636 [PubMed PMID: 80565]
Level 3 (low-level) evidenceHegg R, Lee AG, Tagg NT, Zimmerman MB. Statin or nonsteroidal anti-inflammatory drug use is associated with lower erythrocyte sedimentation rate in patients with giant cell arteritis. Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society. 2011 Jun:31(2):135-8. doi: 10.1097/WNO.0b013e31820c4421. Epub [PubMed PMID: 21358421]
Level 2 (mid-level) evidenceYago M, Pla C. Reference-mean-centered statistical quality control. Clinical chemistry and laboratory medicine. 2020 Aug 27:58(9):1517-1523. doi: 10.1515/cclm-2019-1034. Epub 2020 Jan 13 [PubMed PMID: 31926071]
Level 2 (mid-level) evidenceBruno LC. IQCP: Guideline and Helpful Tools for Implementation. Laboratory medicine. 2016 Nov:47(4):e42-e46 [PubMed PMID: 27708173]
Poh DKH, Lim CY, Tan RZ, Markus C, Loh TP. Internal quality control: Moving average algorithms outperform Westgard rules. Clinical biochemistry. 2021 Dec:98():63-69. doi: 10.1016/j.clinbiochem.2021.09.007. Epub 2021 Sep 14 [PubMed PMID: 34534518]
Level 2 (mid-level) evidenceBorn PH, Thran SL. The influence of CLIA '88 on physician office laboratories. The Journal of family practice. 1998 Apr:46(4):319-27 [PubMed PMID: 9564374]
Badrick T. Integrating quality control and external quality assurance. Clinical biochemistry. 2021 Sep:95():15-27. doi: 10.1016/j.clinbiochem.2021.05.003. Epub 2021 May 7 [PubMed PMID: 33965412]
Level 2 (mid-level) evidenceMeisenhelder J, Bursik S, Lunn G, Strober W. Laboratory safety. Current protocols in human genetics. 2008 Apr:Appendix 2():Appendix 2A. doi: 10.1002/0471142905.hga02as57. Epub [PubMed PMID: 18428418]
Burnett LC, Lunn G, Coico R. Biosafety: guidelines for working with pathogenic and infectious microorganisms. Current protocols in microbiology. 2009 May:Chapter 1(1):Unit 1A.1. doi: 10.1002/9780471729259.mc01a01s13. Epub [PubMed PMID: 19412909]
Level 3 (low-level) evidence