Beruflich Dokumente
Kultur Dokumente
Department of Haematology, the erythrocyte sedimentation rate (ESR), the International Council for
Imperial College Faculty of
Medicine, Hammersmith Hospital,
Standardization in Haematology makes the following recommenda-
London, UK tions: (i) The reference method for measurement of the ESR should be
Department of Haematology based on the Westergren method, which is a specific test for the ESR,
Evaluation, University College with modifications, (ii) The reference method for measurement of the
London Hospital, London, UK
Department of Haematology, St ESR should use either whole blood anticoagulated with EDTA and later
George Hospital, Sydney, NSW, diluted with sodium citrate or saline (4 : 1) or whole blood anticoag-
Australia ulated with sodium citrate (4 : 1) in Westergren pipettes, (iii) The ESR
General Haematology, UK
pipettes can be of glass or plastic (with specific characteristics). It must
NEQAS, Watford, UK
**ICSH Communications Secretary, be colourless; a minimum sedimentation scale of 200 mm, a minimum
Columbus, OH, USA bore of 2.55 mm, which should be constant within 5%. A protocol for
the evaluation of alternative methodologies against the reference
Correspondence:
Dr J. M. Jou, Servei Hemotera`pia
method is outlined: The new technologies must be tested over a range
i Hemosta`sia, Core Laboratory, of ESR values of 2120 mm. In this comparison, 95% of the differences
Centre de Diagno`stis Biome`dic, should be 5 mm or less, with larger differences associated with higher
Hospital Clnic, University of ESR values. A minimum of 40 samples should be tested in 3 different
Barcelona, VIllarroel 170, 08036
Barcelona, Spain. groups of values: 120, 2160 and more than 60 mm. The statistical
Tel.: +34.932279375; methods recommended for ESR evaluations are the coefficient of
Fax: +34.932279376; correlation, the Passing-Bablock regression and the Bland-Altman
E-mail: jmjou@clinic.ub.es
statistical method. This reference method replaces all earlier standard-
doi:10.1111/j.1751-553X.2011.01302.x ized and reference methods.
Keywords
Erythrocyte sedimentation rate,
reference method, standardized
method, blood sedimentation,
Westergren, laboratory instrumen-
tation, methodology
2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 125132 125
126 J. M. JOU ET AL. ICSH REVIEW OF MEASUREMENT OF ESR
2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 125132
J. M. JOU ET AL. ICSH REVIEW OF MEASUREMENT OF ESR 127
that the term erythrocyte sedimentation rate (ESR) A search in PubMed (from 1921 to 2010) citation
was retained because of traditional usage, although a index identified 16386 papers that used the term ESR.
single measurement after 60 minutes is not a rate. The The ESR does not measure an analyte but rather a
uses of undiluted EDTA samples with a PCV of 0.35 or physical phenomenon that depends on a large number
less was recommended for performing the reference of variables. The ESR is a nonspecific screening test
method. The standardized method was described as the used to detect the acute phase inflammatory response
same as the reference method with the only exception (Bain, 1983; Lewis, 2006; Briggs, 2009) and to monitor
that glass and certain plastic pipettes could be used for chronic processes (Zlonis, 1993). The test is mainly influ-
the traditional Westergren method. The main reason enced by proteins (Gabay & Kushner, 1999), room tem-
for both methods was to use them for verification, perature (Manley, 1957) and the presence of anaemia,
quality control and to establish comparability of the which cause a false high reading, although some publica-
results obtained with routine (working, selected) tions give a formula to correct the results (Fabry, 1987).
methods. This paper described very clearly that the ref- The usefulness of the ESR has been widely debated
erence values and the ESR results had to be expressed in the literature for many years (Weinstein & Del Giu-
as for diluted blood at 60 min or normalized to 60 min. dice, 1994; Saadeh, 1998; Plebani, 2003). Its clinical
For comparison of results between the reference and utility has been demonstrated in editorial papers
standardized method and the routine method, the for- (Brigden, 1999; Brigden & Heathcote, 2000; Reinhart,
mula routine Westergren method (diluted) = (undi- 2006) and in reports concerning primary care assistance
luted Westergren method 0.86))12 must be used (Sox & Liang, 1986; Gronlie & Hjortdahl, 1991; Thue,
(ICSH 1988). ICSH-1993 also included a table for Sandberg & Fugelli, 1994), the elderly (Kat et al., 1989;
accepting the results of any comparability as correct Smith & Samadian, 1994; Stevens, Tallis & Hollis,
and stated that the results should be expressed as 1995), hospital patients (Lluberas-Acosta & Schumach-
ESR = x mm. er, 1991; Olshaker & Jerrard, 1997), haematological
malignancies (Haybittle et al., 1985; Alexandrakis et al.,
2003), stroke (Vila & Chamorro, 1995), heart disease
Other standardization documents
(Gillum, Mussolino & Makuc, 1995; Erikssen et al.,
Parallel documents were published by the NCCLS 2000; Rapaport, 2000; Wu et al., 2002; Danesh, 2004),
(1993) and its successor the CLSI (2000), as well as by rheumatoid arthritis (Combe et al., 2001; Wolfe & Pin-
various national standards authorities, inter alia in the cus, 2001), giant-cell arteritis (Zweegman, Makkink &
BSI (1987) in the United Kingdom and the DIN Stehouwer, 1993; Nuenninghoff et al., 2003; Trejo-Gut-
(1997) in Germany. WHO (1993) has also published a ierrez, Larson & Abril, 2008), spondylitis (Spoorenberg
technical broadsheet describing the ICSH standard, et al., 1999), renal carcinoma (Ljungberg, Grankvist &
intended especially for under-resourced countries. The Rasmuson, 1995), prostatic cancer (Johansson et al.,
CLSI (2010) document was recently revised, and 1992a,b), rheumatic polymyalgia (Salvarani et al.,
International Standardization Organization (ISO) is in 2005) infection (Greidanus et al., 2007; arthroplastia
train to establish an international standard based on (Austin et al., 2008), anaemia (Robins, Khan & Atrak,
the BSI standard. 2003; Winsor & Burch, 1994) and other diseases. Now-
adays, it seems that many physicians worldwide use the
clinical utility of this test, with intrinsic limitations, for
CLINICAL APPLICATIONS OF THE ESR
diagnostic purposes or general screening of patient
The ESR test is a laboratory test that serves as a gen- health.
eral sickness index in conjunction with the patients
clinical history and physical examination findings
REVIEW OF THE LITERATURE: USE OF THE
(Koepke, 2002a). Therefore, it has been a popular
ESR REFERENCE AND STANDARDIZED
procedure for many years, as it is useful to have this
METHODS
information available to the physician quite quickly
after seeing the patient to decide on appropriate steps Since 1991, many evaluations of new ESR analysers
for care (Koepke, 2002b). have been published. Very few of these publications
2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 125132
128 J. M. JOU ET AL. ICSH REVIEW OF MEASUREMENT OF ESR
used the reference method with undiluted EDTA sam- Westergren method with diluted blood at 60 min or
ples (Caswell & Stuart, 1991; Plebani et al., 1998; normalized to 60 min as recommended by ICSH-1993
Ozdem et al., 2006) and did not apply the comparison are the only ones that have clinical value. It is impor-
table included in ICSH-1993. The formula from ICSH- tant to recognize that the Westergren method is a spe-
1993 is used to compare the results of reference and cific test for the ESR. Other equivalent tests must
standardized methods with the instruments, which establish their own normal reference ranges and levels
always give the results as values of diluted samples as of clinical utility, sensitivity and specificity.
recommended by ICSH-1993. In most evaluations,
new analyser methods were compared with the stan-
ICSH REFERENCE METHOD FOR
dardized method with diluted samples (Thomas &
MEASUREMENT OF THE ESR
Karpic, 1993; Happe et al., 2002; Romero, Munoz &
Ramirez, 2003; Al-Fadhli & Al-Awadhi, 2005; Ajubi,
Aim
Bakker & van den Berg, 2006; Mahlangu & Davids,
2008; Shelat, Chacosky & Shibutani, 2008; Alexy, Pais In the year 1993, the ICSH proposed reference and
& Meiselman, 2009; Hardeman et al., 2010a,b; Pero- standardized methods, using undiluted EDTA antico-
vic, Bakovic & Valcic, 2010). As an example, in one agulated samples, with haematocrit of 0.35 or less
paper (Cha et al., 2009) undiluted samples and glass under standardized conditions in a Westergren open-
pipette were used for reference method when com- ended glass pipette that meets ICSH-1993 specifica-
paring with an analyser which gives the results as tions (ICSH 1993). Comparison of the results
diluted samples. The conclusion of this study was that obtained by routine (selected, working) methods was
the Westergren method did not perform as well as the by means of a formula and a table. This was a signif-
analyser. However, this conclusion is invalid, because icantly revised version of the previous ICSH recom-
of a failure to correct the results of undiluted samples mendations and was intended to provide a reference
according to the ICSH-1993 guidelines. This problem method for verifying the reliability of any modifica-
has occurred in other papers when discussing the tion of the test used in practice, especially new tech-
Westergren method (reference/standardized) because nologies. This ICSH method required the test to be
the authors use this name generically whether using carried out on EDTA blood not diluted in citrate,
undiluted or diluted samples, glass or plastic pipettes using specified Westergren tubes and using an exper-
and manual or semi-automated methods. imentally derived formula for correction. This enables
a correction chart to be compiled, and any new
method could be considered satisfactory if 95% of
EVALUATION OF NEW ANALYSERS
results on samples at any measured ESR were within
Nowadays, the traditional Westergren method is not the reference range. However, this technique and
generally used in routine laboratories except in some the interpretation of the acceptable range for any
developing countries. Many new technologies and routine method have been found to be a much more
analysers have been developed for measurement of complicated procedure, unlikely to be universally
the ESR (Caswell & Stuart, 1991; Plebani et al., 1998; adopted in practice.
de Jonge et al., 2000; Piva et al., 2001; Happe et al., Because of the misleading interpretations of the
2002; Al-Fadhli & Al-Awadhi, 2005; Ozdem et al., reference method and the confusion as to how to use
2006; Osei-Bimpong, Meek & Lewis, 2007; Mahlangu the standardized method, the ICSH expert panel has
& Davids, 2008; Shelat, Chacosky & Shibutani, 2008; established changes of the recommendations for the
Alexy, Pais & Meiselman, 2009; Perovic, Bakovic & reference method and eliminated the standardized
Valcic, 2010). Some of these involve automation of method.
the Westergren method with diluted or undiluted ICSH confirms that the term Erythrocyte Sedimenta-
samples while others use very new technologies. The tion Rate (ESR) is retained because of traditional usage
latter tend to use undiluted EDTA samples for ease of and to prevent confusion although, as stated above, a
use, economy, practicability, closed sample manipula- single measurement after 60 min is not a rate. It has
tion and speed. The systems that give the results as been suggested (Plebani et al., 1998; Piva et al., 2001)
2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 125132
J. M. JOU ET AL. ICSH REVIEW OF MEASUREMENT OF ESR 129
that the name ESR should be changed to Length Sedi- Pipette holding device
mentation Reaction in Blood (LSRB) but other authors
The pipette should be held vertically, protected from
are not of the same opinion (Hardeman, 2007a,b). The
direct sunlight, draughts and vibration and kept at a
ICSH does not accept the suggested new name.
constant temperature (1 C) within the range
1825 C during the sedimentation period.
Blood sample
2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 125132
130 J. M. JOU ET AL. ICSH REVIEW OF MEASUREMENT OF ESR
variables influence the ESR and may therefore affect globin concentration, medication, menstrual cycle,
physiological reference values, most notably haemo- pregnancy and smoking (Miao, 2002).
Cha C.H., Park C.J., Cha Y.J., Kim H.K., Kim C.P. (2007) Use of erythrocyte sedimentation
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