Erythrocyte Sedimentation Rate (ESR) Test & Normal Levels
The erythrocyte sedimentation rate (ESR) blood test checks for chronic inflammation, but it’s not sensitive. Often called the “sickness index,” doctors can also use it to track the progress of specific diseases. Read on to find out how ESR works, what can impact ESR levels in your body, and how this lab marker relates to your health.
What Is the Erythrocyte Sedimentation Rate (ESR)?
Erythrocyte sedimentation rate (ESR) was discovered in 1987 [1, 2].
The ESR is the rate at which red blood cells (erythrocytes) sink to the bottom (sedimentation) of a tube in one hour [3, 4].
The main factors affecting ESR are hematocrit (percentage of red blood cells in your blood) and blood proteins, such asfibrinogen .
Erythrocyte Sedimentation Rate (ESR) Blood Test
Erythrocyte sedimentation rate (ESR) test or “sed rate test”, is a blood test that checks for inflammation. It measures the distance in millimeters that red blood cells fall in one hour (mm/hr) [6, 7].
There are a few ways that this is measured, such as the Westergren method, Wintrobe Method, MicroESR, and automated methods [8, 9, 10].
The Westergren method is considered the gold standard in measuring ESR .
The blood sample is mixed with sodium citrate (4:1). Then it is mixed into a Westergren-Katz tube (2.5 mm diameter) until the 200 mm mark.
Next, the tube is set vertically, at room temperature (18 – 25 °C), for one hour.
At the end of an hour, they measure how far the red blood cells have settled. This distance is ESR.
In the modified Westergren method, edetic acid is used instead of sodium citrate [8, 9, 10].
The Wintrobe method is less sensitive than the Westergren method and the maximal values may be misleading [12, 13].
The micro ESR method is quick (20 min) and popular for babies, as the test requires very little blood. It is also useful for diagnosing neonatal sepsis [14, 15, 16].
Automated methods are faster, easy to use, and could be better predictors for autoimmune diseases. Yet, their sensitivity to technical procedures (blood mixing, tube sizes, etc.) could influence the test results [17, 18, 19, 20, 21, 22, 23, 24].
ESR is most commonly measured using the Westergren method. Micro ESR can be used in newborns and it requires only a small amount of blood.
When to Get a Sed Rate Test
Your doctor may order an ESR test if you have the following symptoms :
What Can The ESR Test Reveal?
Factors and disease shown here are commonly associated with abnormal ESR values. Work with your doctor or other health care professional for an accurate diagnosis.
The ESR test checks if you have an inflammation .
In inflammation, certain proteins will appear in the blood, such as fibrinogen. These proteins cause red blood cells to cling together and form clumps. This makes them heavier, so they fall faster, which increases the ESR [5, 26, 3].
Therefore, high ESR shows inflammation. The higher the ESR level, the higher the inflammation [5, 26, 3].
But, the ESR test is not very sensitive (so it can’t pick up all inflammation) nor specific, so it can not diagnose specific diseases .
2) Screening for Specific Diseases
The ESR test could help with the diagnosis of certain diseases:
- Polymyalgia rheumatica (an inflammatory disease which causes muscle pain and stiffness) [27, 28, 29]
- Giant cell arteritis (inflammation of blood vessels) [30, 31, 32, 33, 34]
- Cancer [35, 36]
- Bone infections [37, 38, 39]
- Subacute thyroiditis (inflammation of the thyroid) [40, 41, 42]
- Ulcerative colitis 
3) Progression of Specific Conditions
The ESR test cannot diagnose diseases, but it can track the progress of specific conditions :
- Heart disease [45, 46, 47]
- Cancer [48, 5, 49]
- Rheumatoid arthritis [50, 51, 52]
- Systemic lupus erythematosus (SLE) [53, 54]
- Sickle-cell disease [55, 56, 57]
4) Serious Conditions
ESR levels higher than 100 mm/hr could suggest a serious disease, such as infection, heart disease, or cancer [58, 5, 3, 6].
ESR levels higher than normal may predict cancer or cancer progression, like metastasis [59, 60, 61, 62, 63].
Your doctor may order an ESR test to check for specific inflammatory or chronic conditions, along with other tests. ESR is considered a non-specific, non-sensitive marker of chronic inflammation.
Normal ESR Levels
|Younger than 50||0-15 mm||0-20 mm|
|Older than 50||0-20 mm||0-30 mm|
Children should have an ESR lower than 10mm .
A low ESR is normal and does not cause any symptoms .
Factors That Increase ESR Levels
Disorders and diseases:
- Inflammation, infection, or malignant diseases can increase ESR rates [3, 5, 26, 64, 65, 66]
- Women tend to have higher ESR rates [3, 6, 5, 67]
- Old age [3, 6, 5, 67, 68]
- Anemia; reduced hematocrit increases ESR levels [3, 5, 6, 65]
- Macrocytosis (large red blood cells) [3, 5]
- Polycythemia (increased production of red blood cells) [3, 5, 69, 8, 70]
- Increased fibrinogen levels [3, 5]
- Pregnancy [71, 72]
- Diabetes [3, 5, 73]
- Kidney failure 
- Chronic heart failure 
- Obesity [6, 5]
- Hyperlipidemia (high concentrations of fats in the blood) 
- Heart disease [77, 45, 46]
- Polymyalgia rheumatica (an inflammatory disorder where there is muscle pain around the shoulders and hips) [78, 28, 79]
- Subacute thyroiditis 
- Alcoholic liver disease, which can cause decreased albumin production, and thus increase ESR 
- Crohn’s disease and ulcerative colitis [81, 82]
- Kidney failure 
- Temporal/giant cell arteritis (inflammation in blood cells around the scalp) [83, 84]
- Multiple myeloma 
- Waldenstrom’s macroglobulinemia (tumors that make large amounts of immunoglobulins) [86, 87]
- Atherosclerosis (plaque buildup in the arteries) and stroke 
- Cancer risk, progression, and death [35, 89, 90]
Many inflammatory disorders and chronic diseases are associated with high ESR values.
Drugs and supplements:
- Iodine, when it causes thyroid problems 
- High ginger consumption, when it’s linked to subacute thyroiditis 
- Birth control 
- Smoking [94, 95, 96, 97]
- Alcohol [80, 98]
- Dextran 
Technical errors during the test such as a tilted tube or dilution error can also give a false high ESR result .
Factors That Decrease ESR Levels
When red blood cells are smaller, they will drop slower, hence a lower ESR.
- Red blood cells diseases: extreme leukocytosis, polycythemia, microcytosis, sickle cell disease, spherocytosis, acanthocytosis, and anisocytosis [3, 5, 69, 8, 55]
- Protein abnormalities: hypofibrinogenemia, hypogammaglobulinemia, and dysproteinemia with hyperviscosity state [3, 5, 8, 65, 100, 70]
- NSAIDs, cortisone, anesthetic drugs, levamisole, and prednisone [101, 5, 8, 102, 84]
Low ESR is usually normal, but some factors that excessively lower red blood cells have also been linked to low ESR values.
Genes That Affect ESR
These SNPs/genes are associated with a higher ESR:
- rs3750996 (G/G) , rs3750996 (G-C) 
- rs2066865 (C>T) (minor allele) 
- rs3750994 (G-C) is related to higher ESR levels 
High fibrinogen levels make the red blood cells heavier and increase the ESR. So, genes increasing fibrinogen production could theoretically increase ESR levels. These include:
- rs2070006 (T>C) 
- rs2070011 (T>C) [105, 106]
- rs6050 (G>A) (major allele) [107, 108]
- rs1800790 (G>A) (minor allele) [107, 109, 110, 105]
- rs1800791 (G>A) [111, 106]
- rs2227399 (G>T) 
- rs4220 (G>A) [105, 106]
- rs7439150 (G>A) [111, 112]
- rs1049636 (T>C) [111, 106]
These SNPs/genes are associated with lower ESR levels:
- rs630337 (T/C) 
- rs11117956 (T/G) 
- rs11549407 (A/G) 
- rs650877 (G/A) 
- rs11118131 (T/C) 
- rs677066 (G/A) 
- rs6691117 (G/A) 
- rs12034383 (G/A) 
- rs1043879 
- rs3091242 
- rs873308 
- rs10903129 
- rs7527798 
Low fibrinogen levels make the red blood cells lighter and decrease the ESR. So, genes decreasing fibrinogen production may theoretically reduce ESR levels:
- rs1800787 (C>T) is associated with low fibrinogen, slow initiation of the coagulation cascade, and possibly childhood pneumonia [106, 115].
- rs148685782 (G>C) is associated with low blood fibrinogen levels and hypofibrinogenemia [116, 117].
ESR and C-Reactive Protein (CRP)
In inflammation, the liver is producing a protein called C-reactive protein (CRP).The CRP blood test checks whether you have inflammation or infection. CRP levels higher than 10 mg/dL show infection [118, 119, 120].
CRP test is used most times together with the ESR test [121, 122, 123].
C-reactive protein is more sensitive than ESR and produces less false negative/false positive results than ESR .
CRP is better for checking and tracking the progress of acute inflammations, and infections [25, 121, 122].
ESR is better for checking and tracking the progress of chronic inflammations, and infections [25, 121, 122].
Both ESR and CRP can increase with inflammation, but CRP may be a better marker of acute and ESR of chronic inflammation and infection.
Limitations and Caveats
While there are many studies examining ESR, almost all of them are population-based, which means they can associate high or low ESR values with certain conditions but not establish them as their cause. Additional limitations of some of these studies include being based on older data or only conducted with men.
More clinical trials investigating ESR should be undertaken.
Erythrocyte sedimentation rate (ESR) test or “sed rate test” is a blood test that checks for inflammation.
It is most commonly measured using the Westergren method, the gold standard in assessing ESR. Micro ESR is another method that can be used in newborns that requires only a small amount of blood.
Your doctor may order an ESR test if you show signs or symptoms of infection or inflammation, such as fever, headache, and pain. They may also order this test to screen for specific diseases or to monitor chronic autoimmune diseases like lupus and rheumatoid arthritis.
The normal ESR range should be below 15 or 30 mm, depending on gender and age.
About the Author
Dr. Puya Yazdi is a physician-scientist with 14+ years of experience in clinical medicine, life sciences, biotechnology, and nutraceuticals.
As a physician-scientist with expertise in genomics, biotechnology, and nutraceuticals, he has made it his mission to bring precision medicine to the bedside and help transform healthcare in the 21st century. He received his undergraduate education at the University of California at Irvine, a Medical Doctorate from the University of Southern California, and was a Resident Physician at Stanford University. He then proceeded to serve as a Clinical Fellow of The California Institute of Regenerative Medicine at The University of California at Irvine, where he conducted research of stem cells, epigenetics, and genomics. He was also a Medical Director for Cyvex Nutrition before serving as president of Systomic Health, a biotechnology consulting agency, where he served as an expert on genomics and other high-throughput technologies. His previous clients include Allergan, Caladrius Biosciences, and Omega Protein. He has a history of peer-reviewed publications, intellectual property discoveries (patents, etc.), clinical trial design, and a thorough knowledge of the regulatory landscape in biotechnology. He is leading our entire scientific and medical team in order to ensure accuracy and scientific validity of our content and products.
The information on this website has not been evaluated by the Food & Drug Administration or any other medical body. We do not aim to diagnose, treat, cure or prevent any illness or disease. Information is shared for educational purposes only. You must consult your doctor before acting on any content on this website, especially if you are pregnant, nursing, taking medication, or have a medical condition.
Erythrocyte Sedimentation Rate Test (ESR Test)
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What is an ESR test?
An erythrocyte sedimentation rate (ESR) test is sometimes called a sedimentation rate test or sed rate test. This blood test doesn’t diagnose one specific condition. Instead, it helps your healthcare provider determine whether you’re experiencing inflammation.
Your doctor will look at ESR results along with other information or test results to help figure out a diagnosis. The tests ordered will depend on your symptoms.
The ESR test can also be used to monitor inflammatory diseases.
Why doctors request an ESR test
When you’re experiencing inflammation, your red blood cells (RBCs) cling together, forming clumps. This clumping affects the rate at which RBCs sink inside a tube where a blood sample is placed.
The test lets your doctor see how much clumping is occurring. The faster and further the cells sink towards the bottom of a test tube, the more likely it is that inflammation is present.
The test can identify and measure inflammation, in general, in your body. However, it doesn’t help pinpoint the cause of inflammation. That’s why the ESR test is rarely performed alone. Instead, your doctor will likely combine it with other tests to determine the cause of your symptoms.
The ESR test can be used to help your healthcare provider diagnose conditions that cause inflammation, such as:
The ESR test can help your healthcare provider monitor autoimmune inflammatory conditions, such as:
Your doctor might also order this test if you have:
Preparing for the ESR test
The ESR test requires little preparation.
However, you should tell your doctor if you’re taking any medication therapy. They may ask you to temporarily stop taking it before the test. Certain medications may affect ESR test results.
The ESR test
This test involves a simple blood draw. It should take only a minute or two.
- First, the skin directly over your vein is cleaned.
- Then, a needle is inserted to collect your blood.
- After collecting your blood, the needle is removed and the puncture site covered to stop any bleeding.
The blood sample is taken to a lab, where your blood will be placed in a long, thin tube in which it sits to gravity for one hour. During and after this hour, the laboratory professional processing this test will assess how far the RBCs sink into the tube, how quickly they sink, and how many sink.
Inflammation can cause abnormal proteins to appear in your blood. These proteins cause your RBCs to clump together. This makes them fall more quickly.
Your doctor may order a C-reactive protein (CRP) test at the same time as your ESR test. CRP measures inflammation as well, but it can also help predict your risk for coronary artery disease (CAD) and other cardiovascular diseases.
Risks of the ESR test
Having your blood drawn involves minimal risks. Possible complications include:
You’ll probably feel mild to moderate pain when the needle pricks your skin. You might also feel throbbing at the puncture site after the test.
If you’re uncomfortable at the sight of blood, you may also experience discomfort seeing blood drawn from your body.
Different types of ESR tests
There are two methods for measuring your erythrocyte sedimentation rate.
In this method, your blood is drawn into a Westergren-Katz tube until the blood level reaches 200 millimeters (mm).
The tube is stored vertically and sit at room temperature for an hour.
The distance between the top of the blood mixture and the top of the sedimentation of RBCs is measured.
This is the most used ESR testing method.
The Wintrobe method is similar to the Westergren method, except the tube used is 100 mm long and thinner.
A disadvantage of this method is that it’s less sensitive than the Westergren method.
Normal ESR test results
ESR test results are measured in millimeters per hour (mm/hr).
The following are considered normal ESR test results:
- Women under age 50 should have an ESR between 0 and 20 mm/hr.
- Men under age 50 should have an ESR between 0 and 15 mm/hr.
- Women over age 50 should have an ESR between 0 and 30 mm/hr.
- Men over age 50 should have an ESR between 0 and 20 mm/hr.
- Children should have an ESR between 0 and 10 mm/hr.
The higher the number, the higher the likelihood of inflammation.
Understanding abnormal ESR test results
An abnormal ESR result doesn’t diagnose any particular disease. It just identifies any potential inflammation in your body and indicates a need to look further.
An abnormally low value would be near 0. (Because these tests fluctuate, and what is ultimately considered too low may vary from one person to the next, it’s hard to state an exact value.)
This test isn’t always reliable or meaningful. Many factors can alter your results, such as:
Some causes of abnormal ESR test results are more serious than others, but many aren’t a huge concern. It’s important not to worry too much if your ESR test results are abnormal.
Instead, work with your doctor to find out what’s causing your symptoms. They’ll usually order follow-up tests if your ESR results are too high or low.
Causes of high ESR test results
There are multiple causes of a high ESR test result. Some common conditions associated with a higher rate include:
An abnormally high ESR can indicate the presence of cancerous tumors, especially if no inflammation is found.
ESR test results that are higher than normal are also associated with autoimmune diseases, including:
Some types of infection that cause ESR test results to become higher than normal are:
What happens after the test
Depending on your results, your doctor may want to order additional tests, including a second ESR test to verify the results of the first one. These tests can potentially help your doctor to figure out the specific cause of your inflammation.
If you have a condition that falls into one of the categories below, further tests can also help measure the effectiveness of treatments and keep track of your ESR throughout your course of treatment.
An underlying condition
If your healthcare provider suspects that an underlying condition is causing your high ESR, they may refer you to a specialist who can properly diagnose and treat the condition.
If your doctor detects inflammation, they may recommend one or more of the following treatments:
If a bacterial infection is causing your inflammation, your doctor will likely prescribe an antibiotic to fight this infection.
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Raised erythrocyte sedimentation rate signals heart failure in patients with rheumatoid arthritis
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Sedimentation Rate (Sed Rate)
The sedimentation rate (sed rate) blood test measures how quickly red blood cells (erythrocytes) settle in a test tube in one hour. The more red cells that fall to the bottom of the test tube in one hour, the higher the sed rate.
When inflammation is present in the body, certain proteins cause red blood cells to stick together and fall more quickly than normal to the bottom of the tube. These proteins are produced by the liver and the immune system under many abnormal conditions, such as an infection, an autoimmune disease, or cancer.
There are many possible causes of a high sedimentation rate. For this reason, a sed rate is done with other tests to confirm a diagnosis. After a diagnosis has been made, a sed rate can be done to help check on the disease or see how well treatment is working.
Why It Is Done
A sedimentation rate (sed rate) test is done to:
- Find out if inflammation or infection is present.
- Check on the progress of a disease.
- See how well a treatment is working.
How To Prepare
You do not need to do anything before you have this test.
Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form .
How It Is Done
The health professional drawing blood will:
- Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein.
- Clean the needle site with alcohol.
- Put the needle into the vein. More than one needle stick may be needed.
- Attach a tube to the needle to fill it with blood.
- Remove the band from your arm when enough blood is collected.
- Apply a gauze pad or cotton ball over the needle site as the needle is removed.
- Apply pressure to the site and then a bandage.
How It Feels
The blood sample is taken from a vein in your arm. An elastic band is wrapped around your upper arm. It may feel tight. You may feel nothing at all from the needle, or you may feel a quick sting or pinch.
There is very little chance of a problem from having a blood sample taken from a vein.
- You may get a small bruise at the puncture site. You can reduce the risk of bruising by keeping pressure on the site for several minutes after the needle is withdrawn.
- In rare cases, the vein may become inflamed after the blood sample is taken. This condition is called phlebitis and is usually treated with a warm compress applied several times daily.
The sedimentation rate (sed rate) blood test measures how quickly red blood cells (erythrocytes) settle in a test tube.
The normal values listed here—called a reference range—are just a guide. These ranges vary from lab to lab, and your lab may have a different range for what's normal. Your lab report should contain the range your lab uses. Also, your doctor will evaluate your results based on your health and other factors. This means that a value that falls outside the normal values listed here may still be normal for you or your lab.
Results are usually available right away.
0–15 millimeters per hour (mm/hr), or 0–20 mm/hr for men older than 50
0–20 mm/hr, or 0–30 mm/hr for women older than 50
High sedimentation rates may be caused by:
- Autoimmune diseases, such as systemic lupus erythematosus or rheumatoid arthritis.
- Cancer, such as lymphoma or multiple myeloma.
- Chronic kidney disease.
- Infection, such as pneumonia, pelvic inflammatory disease, or appendicitis.
- Inflammation of joints (such as polymyalgia rheumatica) and blood vessels (such as giant cell arteritis).
- Inflammation of the thyroid gland (Graves' disease).
- Kidney, bone, joint, skin, or heart valve infections.
- Pregnancy and preeclampsia (toxemia of pregnancy).
- Viral infections.
Low values may be caused by:
What Affects the Test
Reasons you may not be able to have the test or why the results may not be helpful include:
- Having your menstrual period.
- Medicines. Many medicines can change the results of this test. Be sure to tell your doctor about all the nonprescription and prescription medicines you take.
What To Think About
- Even though some problems, such as giant cell arteritis, almost always cause a high sedimentation rate (sed rate), the test can't be used by itself to identify a specific disease. Results of a sed rate test are considered along with your symptoms, other test results, and medical information.
- Some diseases that cause inflammation do not increase the sed rate, so a normal sed rate does not always rule out a disease.
- Some doctors use the C-reactive protein (CRP) blood test instead of the sed rate test to help identify inflammatory conditions. To learn more, see the topic C-Reactive Protein (CRP).
- Fischbach FT, Dunning MB III, eds. (2009). Manual of Laboratory and Diagnostic Tests, 8th ed. Philadelphia: Lippincott Williams and Wilkins.
Current as of: August 5, 2020
Author: Healthwise Staff
Anne C. Poinier MD - Internal Medicine
Martin J. Gabica MD - Family Medicine
E. Gregory Thompson MD - Internal Medicine
Kathleen Romito MD - Family Medicine
Adam Husney MD - Family Medicine
Current as of: August 5, 2020
Author: Healthwise Staff
Medical Review:Anne C. Poinier MD - Internal Medicine & Martin J. Gabica MD - Family Medicine & E. Gregory Thompson MD - Internal Medicine & Kathleen Romito MD - Family Medicine & Adam Husney MD - Family Medicine
Fischbach FT, Dunning MB III, eds. (2009). Manual of Laboratory and Diagnostic Tests, 8th ed. Philadelphia: Lippincott Williams and Wilkins.
45 sed rate
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