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A Comparative Study of Erythrocyte Sedimentation Rate (ESR) using Sodium

citrate and EDTA

Article  in  International Journal of Pharmacy and Biological Sciences · January 2011

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A COMPARATIVE STUDY OF ERYTHROCYTE SEDIMENTATION RATE (ESR) USING

SODIUM CITRATE AND EDTA
Shruti Kumta1, Gireesh Nayak2, Pratapchandra Kedilaya H3, Manjula Shantaram3
1
Department of Biosciences, Division of Biotechnology, Mangalore University, Mangalagangothri, Karnataka, India
2
Yenepoya Specialty Hospital, Kodialbail, Mangalore, Karnataka, India
3
Department of Biochemistry, Yenepoya Medical College, Yenepoya University, Mangalore-575 018, Karnataka, India
*Corresponding Author Email: [email protected]

Short Communication

RECEIVED ON 01-10-2011 ACCEPTED ON 06-10-2011

ABSTRACT
Erythrocyte Sedimentation Rate (ESR) is a marker for inflammation in the body. It is the initial test carried out in order to
detect infection using Westergren tube in which blood is mixed with sodium citrate as an anticoagulant. A study was
performed using blood from various patients with two different anticoagulants among which one was sodium citrate,
commonly used and an alternative to this was Ethylene Diamine Tetra Acetic acid (EDTA). In order to minimise the
volume of withdrawal of blood from patients the study of ESR was undertaken with an anticoagulant such as EDTA which
is used for Complete Blood Count (CBC) test also. Twenty two blood samples were collected from out- patients. The
values of ESR using EDTA showed 4-6 mm less than that of sodium citrate. Thus looking at the results obtained in this
comparative study, ESR can be performed using EDTA blood instead of sodium citrate. This utilises only limited amount of
blood.
KEYWORDS: Erythrocyte Sedimentation Rate (ESR), EDTA, Sodium citrate, Westergren tube

Introduction Westergren are eponymously remembered for

the Fåhræus-Westergren test (abbreviated as
The Erythrocyte Sedimentation Rate (ESR), FW test; in the UK, usually termed Westergren
also known as sedimentation rate or Biernacki test) which uses sodium citrate-coagulated
Reaction, is the rate at which red blood cells specimens2,3. Westergren's normal values, for
sediment in a period of 1 hour. It is a common men 3mm and women 7mm4. Normal values
haematology test that is a non-specific are given in Table 1 as per age and sex.
measure of inflammation. To perform the test,
anti-coagulated blood is placed in an upright The ESR is governed by the balance between
tube, known as a Westergren tube, and the pro-sedimentation factors, mainly fibrinogen,
rate at which the red blood cells fall is and those factors resisting sedimentation,
measured and reported in millimetres per namely the negative charge of the
hour (mm/h). erythrocytes (zeta potential). When an
inflammatory process is present, the high
This test was invented in 1897 by the Polish proportion of fibrinogen in the blood causes
doctor Edmund Biernacki1. In some parts of red blood cells to stick to each other. The red
the world the test continues to be referred to cells form stacks called 'rouleaux,' which settle
as the Biernacki Test (Polish abbreviation: OB = faster. Rouleaux formation can also occur in
393

OdczynBiernackiego). In 1918, the Swedish association with some lymphoproliferative

pathologist Robert SannoFåhræus declared disorders in which one or more
the same and along with Alf VilhelmAlbertsson
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immunoglobulins are secreted in high

amounts. Rouleaux formation can, however,
be a normal physiological finding in horses,
cats, and pigs.
Table 1: Normal ESR values with Sodium citrate as an anticoagulant by Westergren Method 5,6,9

Adults Children
Men Women Newborn Newborn to puberty

<50 years >50 years <50 years >50 years 0 to 2 mm/hr 3 to 13 mm/hr

< 15 mm/hr < 20 mm/hr < 20 mm/hr < 30 mm/hr

Note: mm/hr. = millimetres per hour

Although it can help diagnose some illnesses, Why only sodium citrate is being used as an
an abnormal ESR does not prove that one has anticoagulant normally in clinical laboratory
a certain condition. Other confirmatory tests for performing ESR? In order to confirm this,
are always needed. An increased ESR rate may ESR was performed using yet another
be due to anaemia, cancers such as lymphoma anticoagulant EDTA.
or multiple myeloma, kidney disease,
pregnancy and thyroid disease. An ESR and C-reactive protein (CRP) are both
autoimmune disorder is a condition that markers of inflammation5,6. Generally, ESR
occurs when the immune system mistakenly does not change as rapidly as does CRP, either
attacks and destroys healthy body tissue. ESR at the start of inflammation or as it disappears.
is often higher than normal in people with an CRP is not affected by as many other factors as
autoimmune disorder. Common autoimmune is ESR, making it a better marker of
disorders include lupus erythematosus and inflammation. CRP is an acute phase protein
rheumatoid arthritis in adults or children. produced by the liver during an inflammatory
reaction. Since CRP levels in the blood rise
Very high ESR levels occur with less common more quickly after the inflammatory or
autoimmune disorders including allergic infective process begins, ESR is often replaced
vasculitis, giant cell arthritis, with C-reactive protein measurement. There
hyperfibrinogenemia, and macroglobulinemia are specific drawbacks, however, for example,
- primary necrotizing vasculitis and both tests for ESR and CRP were found to be
polymyalgia rheumatica. An increased ESR rate independently associated with a diagnosis of
may be due to some infections including acute maxillary sinusitis7 so in some cases the
systemic infection, bone infections, infection combination of the two measurements may
of the heart or heart valves, rheumatic fever, improve diagnostic sensitivity and specificity.
severe skin infections such as erysipelas and
tuberculosis. Lower-than-normal levels occur Materials and Methods
with congestive heart failure, This experiment was performed using
hypofibrinogenemia, low plasma protein (due disposable Westergren tubes. The blood of
to liver or kidney disease), polycythemia and OPD of Yenepoya University hospital patients
394

sickle cell anaemia. were collected into two sets of non-vaccum

blood collection vials containing sodium citrate
and EDTA respectively. The sodium citrate
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Manjula Shantaram * et al Int J Pharm Bio Sci
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non-vaccum blood collection vial contained 12. 30 24

3.8% of sodium citrate and EDTA non-vaccum
13. 56 51
blood collection vial contained 8 mg of EDTA in
it. To this 3 ml of blood was added up to the 14. 25 22
mark and mixed by inverting the tubes, three
times. The blood after mixing with 15. 38 37
anticoagulants was kept for ESR within an hour 16. 50 45
of collection of blood from the patients. For
ESR the non-vaccum blood collection vial are 17. 39 31
inserted upright with Westergren tube and left
18. 89 80
as such for 1 hour. The rate of sedimentation
of erythrocytes is measured after 1 hour in 19. 113 107
millimetres. Comparison between ESR of the
20. 26 22
non-vaccum blood collection vial containing
two different anticoagulants is performed and 21. 45 39
the result is given in mm/hr.
22. 83 78
Results and Discussion

As seen from the Table 2, the values of ESR

using EDTA showed comparatively less by 4-6 Although it is frequently recommended, ESR is
mm than that of sodium citrate. of limited use as a screening test in
asymptomatic patients. It is useful for
Table 2: Values of ESR with sodium citrate and EDTA diagnosing diseases, such as multiple myeloma,
blood
polymyalgia rheumatica, various auto-immune
Serial Sodium EDTA blood diseases, systemic lupus erythematosus,
No. citrate blood (mm/hour) rheumatoid arthritis and chronic kidney
(mm/hour) diseases. In many of these cases, the ESR may
exceed 100 mm/hour8.
1. 35 30
It is commonly used for a differential diagnosis
2. 42 36
for Kawasaki's disease, an autoimmune disease
3. 56 51 in which the medium-sized blood vessels
throughout the body become inflamed. It may
4. 30 24 be increased in some chronic infective
5. 25 22 conditions like tuberculosis and infective
endocarditis. It is a component of the PDCAI,
6. 38 32 an index for assessment of severity of
inflammatory bowel disease in children. The
7. 19 13
use of the ESR as a screening test in
8. 46 43 asymptomatic persons is limited by its low
sensitivity and specificity. When there is a
9. 128 124
moderate suspicion of disease, the ESR may
have some value as a "sickness index."
395

10. 19 19

11. 28 24 How can this method be beneficial? While

Page

performing ESR another test known as CBC

International Journal of Pharmacy and Biological Sciences (eISSN: 2230-7605)

Manjula Shantaram * et al Int J Pharm Bio Sci
www.ijpbs.com
 Available Online through
www.ijpbs.com IJPBS |Volume 1| Issue 4 |OCT-DEC |2011|393-396

(Complete Blood Count) is also recommended 3. Robert (Robin) SannoFåhræus and Alf VilhelmAlbertsson
Westergren who are eponymously named for the
by the doctor. The CBC test makes use of Fåhræus-Westergren test (aka Westergren test) at Who
blood mixed with EDTA as an anticoagulant. Named It? Retrieved
So the technicians need to collect blood twice from"http://en.wikipedia.org/wiki/Erythrocyte_sediment
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amount of blood for performing ESR and CBC. sedimentation rate range and limitations of the
As every drop of blood is precious, technique". Triangle3 (1): 1957; 20–25. PMID 13455726.
5. Kushner I, Ballou SP. Acute-phase reactants and the
unnecessary wasting of blood can be concept of inflammation. In: Firestein GS, Budd RC, Harris
minimised, especially in children if ESR is ED, et al, eds. Kelley's Textbook of Rheumatology. 8th ed.
performed by the same blood that is used for Philadelphia, Pa: Saunders Elsevier; 2009; Chapter 52.
6. Pisetsky DS. Laboratory testing in the rheumatic diseases.
CBC. Thus looking at the results obtained in In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed.
this comparative study, ESR can be performed Philadelphia, Pa: Saunders Elsevier; 2007; Chapter 278.
using EDTA blood instead of sodium citrate. 7. Jens Georg Hansen, Henrik Schmidt, JornRosborg,
Elisabeth Lund"Predicting acute maxillary sinusitis in a
This utilises only limited amount of blood, general practice population". BMJ 311 (6999); 22 July
apart from saving in terms of sodium citrate 1995; 233–236. PMC 2550286. PMID 7627042.
and additional non-vacuum blood collection 8. "Sedimentation Rate". WebMD. 2006-06-16.
http://www.webmd.com/a-to-z-guides/sedimentation-
vial. rate. Retrieved 2008-03-01.
9. Mack DR, Langton C, Markowitz J, et al."Laboratory values
References for children with newly diagnosed inflammatory bowel
disease". Paediatrics 119 (6); 2007; 1113–1119.
1. Edmund Faustyn Biernacki and eponymously named doi:10.1542/peds.2006-1865. PMID 17545378. - As
Biernacki's test at Who Named It? Retrieved from commented on at
"http://en.wikipedia.org/wiki/Erythrocyte_sedimentation * Bauchner H (2007-06-13). "Lab Screening in Children
rate". with Suspected Inflammatory Bowel Disease". Journal
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technique". Triangle3 (1) 1957; 20– 25. PMID 13455726. Retrieved 2008-03-01.

*Address for Correspondence:

Dr. Manjula Shantaram
Associate Professor of Biochemistry
Yenepoya Medical College, Yenepoya
University
Mangalore-575018, Karnataka,India.
E. Mail : [email protected]
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