Research Blog

August 29, 2022

Biomarkers of Inflammation and Oxidation: ESR

Optimal Takeaways

The erythrocyte sedimentation rate (ESR) may also be called the “sed rate.” It measures how quickly red blood cells clump and settle in a blood sample. Levels increase as disease activity increases. The ESR is elevated in pathological conditions, including cancer, infection, tissue necrosis, nutritional anemias, renal failure, metabolic syndrome, smoking, rheumatoid arthritis, and other inflammatory disorders. Levels can be decreased in sickle cell anemia, thalassemia, polycythemia vera, spherocytosis, and low fibrinogen.

Standard Range:

Male: 0.00 - 15.00 mm/hr        

Female: 0.00 - 20.00 mm/hr


The ODX Range:            

Male: 0.00 - 5.00 mm/hr          

Female: 0.00 - 10.00 mm/hr

Low ESR can be seen with thalassemia, polycythemia vera, sickle cell anemia, hypofibrinogenemia, and spherocytosis. Drugs that may decrease ESR include cortisone, aspirin, and quinine (Pagana 2021).

High ESR may be caused by bacterial infection, inflammatory disorders, severe nutrient-deficiency anemia, malignant disease, chronic renal failure, necrosis, hyperfibrinogenemia, and macroglobulinemia. Drugs that may increase ESR include oral contraceptives, vitamin A, dextran, methyldopa, penicillamine, procainamide, and theophylline (Pagana 2021).

Increased ESR is also associated with higher BMI, obesity, metabolic syndrome, reduced physical activity, smoking, excessive alcohol consumption, aging (Alende-Castro, 2019), and sarcopenia (van Atteveld 2019)


The erythrocyte sedimentation rate (ESR) measures how quickly RBCs settle in a sample of plasma or saline over a set time. Red blood cells will clump and settle more rapidly under pathological conditions such as advanced cancer, tissue necrosis, infection, and inflammation. This is due to an associated increase in acute-phase plasma proteins such as fibrinogen. The ESR is an acute-phase reactant and is considered a non-specific marker. However, it can be used to monitor disease progression or improvement, especially inflammatory autoimmune disorders. The ESR will increase as disease activity increases and decrease as disease activity decreases (Pagana 2021). The RBC aggregates are called rouleaux.

The ESR has long been used to identify and monitor the acute inflammatory response. Levels will increase within 24-48 hours after insult. However, it is affected by several variables, including methodology, acute protein and immunoglobulin levels, and size, shape, and number of RBCs. Therefore, it is not exceedingly sensitive or specific for the degree of inflammation present. Ideally, ESR should be coupled with CRP for a more accurate assessment. The ESR may be most valuable in monitoring rheumatic disease or orthopedic infection (Lapic 2020).

One retrospective study investigated the utility of ESR and CRP in screening for periprosthetic joint infection. Researchers recommend a 10 mm/hr cut-off and above for identifying infection to avoid commonly mistaken false negatives using the previously accepted cut-off of 30 mm/hr. The recommended cut-off for CRP in the study was 5 mg/L or greater (Bingham 2020).

Increased ESR is also associated with lifestyle and metabolic factors, including higher BMI, obesity, metabolic syndrome, reduced physical activity, smoking, excessive alcohol consumption, and aging (Alende-Castro, 2019). Higher ESR was significantly associated with sarcopenia in the elderly, as demonstrated by decreased strength, slower gait, and lower skeletal muscle mass (van Atteveld 2019)

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Alende-Castro, Vanessa et al. “Factors influencing erythrocyte sedimentation rate in adults: New evidence for an old test.” Medicine vol. 98,34 (2019): e16816. doi:10.1097/MD.0000000000016816

Bingham, Joshua S et al. “Screening for Periprosthetic Joint Infections With ESR and CRP: The Ideal Cutoffs.” The Journal of arthroplasty vol. 35,5 (2020): 1351-1354. doi:10.1016/j.arth.2019.11.040

Lapic, Ivana et al. “Erythrocyte Sedimentation Rate and C-Reactive Protein in Acute Inflammation.” American journal of clinical pathology vol. 153,1 (2020): 14-29. doi:10.1093/ajcp/aqz142

Pagana, Kathleen Deska, et al. Mosby's Diagnostic and Laboratory Test Reference. 15th ed., Mosby, 2021.

van Atteveld, Vera A et al. “Erythrocyte sedimentation rate and albumin as markers of inflammation are associated with measures of sarcopenia: a cross-sectional study.” BMC geriatrics vol. 19,1 233. 27 Aug. 2019, doi:10.1186/s12877-019-1253-5

Tag(s): Biomarkers

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