| Abstract|| |
The objective of this study was to assess the value and determinants of erythrocyte sedimentation rate (ESR) in stable patients on regular hemodialysis (HD). Pre-dialysis and post-dialysis ESR was measured in a group of stable adult patients on regular HD and the results were compared. The results were also correlated with the patients' demographic and laboratory data. Only stable patents were included in the study. Patients with evidence of current infection, active inflammatory processor malignancy and severe anemia were excluded. We recruited 161 patients in the study of whom 44.1% were males, 53.4% had diabetes mellitus and 40.4% had an episode of sepsis previously. Only 15.5% of the patients had less than one year of dialysis and 54.3% were over the age of 60 years. The mean post-dialysis ESR was significantly higher than the pre-dialysis ESR (55.6 ± 30.4 and 49.8 ± 28.5, respectively; P = 0.003). Pre-dialysis, 79.5% of the patients had raised ESR. ESR was significantly correlated with C-reactive protein, serum ferritin, plasma albumin and fibrinogen (P <0.05). Patient factors (age, gender, duration of dialysis, previous renal transplantation, type of dialysis access and sepsis or thrombosis of dialysis access site) and blood laboratory parameters (hemoglobin, serum creatinine and serum parathormone) had no statistically significant correlation with ESR ( P ≥0.05). Post-dialysis the ESR was raised in most of the stable patients on regular HD and was significantly higher than the pre-dialysis ESR (by, on average, 5.8 mm/h). ESR had variable correlation with different blood factors.
|How to cite this article:|
Alsomaili MI, Yousuf M, Hejaili F, Almotairi W, Al-Sayyari AA. Erythrocyte sedimentation rate in stable patients on chronic hemodiaysis. Saudi J Kidney Dis Transpl 2015;26:1149-53
|How to cite this URL:|
Alsomaili MI, Yousuf M, Hejaili F, Almotairi W, Al-Sayyari AA. Erythrocyte sedimentation rate in stable patients on chronic hemodiaysis. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Dec 3];26:1149-53. Available from: https://www.sjkdt.org/text.asp?2015/26/6/1149/168589
| Introduction|| |
Fahraeus first described the accelerated erythrocyte sedimentation rate (ESR) in 1921. Since then, this test has been used as a nonspecific marker of disease.  Zacharski and Kyle  reported from the Mayo Clinic that 58% of the patients with ESR of over 100 mm/h and had underlying malignant disease. Extreme elevation (≥100 mm/h) has been associated with several conditions, including malignancies, infection and collagen vascular diseases.  Thus, many physicians feel it obligatory to undertake extensive diagnostic evaluation in patients found to have extremely high ESR.
The value of measuring ESR in renal patients has not been clear and early reports in the medical literature indicated that 1-17% of the patients with extremely elevated ESR (>100 mm/h) had renal diseases of varying etiologies. , Such data on the dialysis population are scarce and inconclusive. ,
Very few studies have addressed high ESR in patients with end-stage renal disease (ESRD). Bathon et al studied this issue in 48 patients before and after hemodialysis (HD). They concluded that the ESR is high in these patients and found no difference between pre-and post-HD readings. They also concluded that there is no correlation between duration of dialysis, cause of renal failure, level of serum albumin, blood urea nitrogen, creatinine and ESR levels.  In another study from France, Brouillard and his colleagues evaluated ESR in 45 HD patients. They concluded that the ESR was mildly elevated in HD patients in the same way as in the general population. They also concluded that the fibrinogen concentration, globulin level, platelets count and white cell count had a linear correlation with ESR, while hematocrit had an inverse relationship.  These findings were in contrast to the studies by Bathon et al  and Shusterman et al,  who found a mean ESR of 60 and 70 mm/h in similar patients.
Two previous studies have evaluated ESR in patients with renal disease in Saudi Arabia. In the first study, Alhomrany et al  found that up to 30% of such patients had an ESR of more than 32 mm/h in the absence of malignancy or active inflammation. They also found no difference in the ESR levels between stable patients and those having an active disease. In the second study, Yousuf et al  evaluated the causes of extremely elevated ESR of 100 mm/h or more in 505 patients. They found that the ESRD represented the fourth common cause of extreme ESR elevation after infection, malignancy and autoimmune diseases.
We conducted this study to evaluate the magnitude of elevation of ESR among stable patients on chronic HD and to assess the effect of HDs and other associated factors on the ESR value. We also compared post-dialysis ESR with pre-dialysis ESR.
| Patients and Methods|| |
This is a cross-sectional, descriptive, chart review and laboratory-based study. It was conducted at the HD unit of the King Abdul-aziz Medical City, Riyadh, Saudi Arabia. The dialyzers used in all the patients are of biocompatible, high-flux membranes [polysulphone (Hyflux, Fresenius Medical Care AG & Co. KGaA, Bad Homburg, Germany)]. All adult patients on regular HD were approached for inclusion in the study. Patients having an active disease that increased the ESR based on clinical features and other investigations (e.g., connective tissue disorders, malignancy, active infections, pregnancy or on medications like aspirin or antihistamines) were excluded as were the patients having hemoglobin (Hb) levels <70 g/L or patients with sickle cell disease or those unwilling to be included in the study. Patients consented to be included in the study by signing an informed consent form after full explanation of the purpose of the study were recruited in the study.
The demographic data of the patients was obtained from the patients or their relatives and verified from their paper or electronic medical records. The study was approved by the Institutional Review Board.
The demographic data noted included, age, gender, duration on dialysis, cause of chronic kidney disease, presence of diabetes mellitus (DM), frequency of HD/week, type of vascular access, history of renal transplantation, history and number of episodes of vascular access thrombosis or related sepsis.
The laboratory tests included C-reactive protein (CRP), Hb, serum urea, creatinine, albumin, fibrinogen and parathyroid hormone (PTH) levels. Pre-dialysis ESR was performed before the start of the HD session. Another ESR test was carried out within 1 h of the completion of the HD session.
ESR was measured using the modified Westergren method. Blood was collected undiluted in an EDTA tube and transferred to a standard 20 mL Westergren tube within 2 h of being drawn. Blood was allowed to settle at room temperature in a vertical column and one reading was obtained after 1 h. Other required laboratory data were obtained from the hospital computerized physician order entry (CPOE) system. Elevated ESR was defined as more than 25 mm/h while extremely elevated ESR was defined as more than 100 mm/h.
Categorical data were calculated by number and percentage (%) and compared for significance using the chi square test, while continuous data were compared using the student t test. The statistical software used was SPSS ver. 22.0 program. Multiple regression, correlation coefficient and ANOVA were used to compare the groups as needed. Alfa of 0.05 was used as an indication of statistical significance.
| Results|| |
One hundred and sixty-one patients who satisfied the inclusion criteria were included in the study. The pre-dialysis ESR was normal in 20.7%, of the patients. It was mildly (25-59 mm/h), markedly (60-90 mm/h) and extremely (≥100 mm/h) elevated in 42.2%, 33.5% and 3.7% of the patients, respectively. Compared with pre-dialysis ESR, the post-dialysis ESR was not significantly different in any of these four ESR ranges [Table 1].
However, the mean post-dialysis ESR was significantly higher (by a mean of 5.8 mm/h) than the pre-dialysis ESR [55.6 ± 30.4 and 49.8 ± 28.5 mm/h, respectively (0.003)] [Table 1].
We found no significant effect on the pre-dialysis ESR by age (less or more than 60 years), sex, presence or absence or diabetes, duration on HD, vascular access type, history of renal transplantation and previous history of vascular access thrombosis or sepsis [Table 2].
The laboratory parameters that showed a positive correlation with the pre-dialysis ESR were serum ferritin (P = 0.041), CRP (P = 0.012) and plasma fibrinogen (P = 0.0001). Plasma albumin level had a negative statistical correlation with ESR (P = 0.017) [Table 3].
Hb level, serum creatinine and PTH levels had no significant correlation (P >0.05) with ESR [Table 3].
| Discussion|| |
There have been very few reports in the medical literature on the usual range and clinical importance of ESR measurement in the HD patients.
In this study, we evaluated the pre-and post-dialysis ESR and associated factors in stable patients on chronic HD. The pre-dialysis ESR was normal in 20.5% of the patients and was extremely elevated in 3.7% of the patients. This compares with 17.1% (P = 0.47) and 8.8% (P = 0.068), respectively, in the post-dialysis measurements.
We found that ESR was not affected by age, gender, diabetes mellitus, duration and type of dialysis access or previous sepsis or thrombosis of the HD access site. However, it correlates positively to CRP, serum ferritin and plasma fibrinogen level and negatively with the plasma albumin level. Hb, serum creatinine and PTH level had no relationship with ESR. There was no significant difference of ESR before and after HD.
Elevation of ESR (≥25 mm/h) in 79.5% of the ESRD patients in our study compares with 93% and 90% in studies by Bathon et al  and Alhomrany,  respectively. In these two studies, there was extreme elevation of ESR in 20% and 32% of the patients, respectively. A mean ESR of about 50 mm/h in our study compared with 70, 60 and 39 mm/h in studies by Bathon et al,  Shusterman et al  and Brouillard et al,  respectively.
Unlike in our study, other studies by Bathon et al  and Alhomrany  did not find any significant difference between ESR before and after dialysis.
The impact of different factors affecting ESR in ESRD patients has been conflicting in different studies. In our study, the only factors correlating with ESR were CRP, plasma albumin, fibrinogen and serum ferritin. However, Bathon et al  found only correlation of plasma albumin and ESR while Alhomrany  found fibrinogen as the only factor correlating with ESR and did not find any correlation of anemia with ESR. We also found no correlation of anemia with ESR. As in our study, Brouillard et al  also found that the fibrinogen levels were significantly correlating with ESR.
Although different studies showed an increase in the mean ESR after HD, no study has documented the change in the ESR in the form of increase or decrease in certain patients after HD. Why this change occurs is unclear.
Conflict of interest: None declared.
| References|| |
Fahraeus R. The suspension stability of the blood. Acta Med Scand 1921;55:70-92.
Zacharski LR, Kyle RA. Significance of extreme elevation of erythrocyte sedimentation rate. JAMA 1967;202:264-6.
Wyler DJ. Diagnostic implications of markedly elevated erythrocyte sedimentation rate: A reevaluation. South Med J 1977;70:1428-30.
Kerkeby A, Leren P. Significance of greatly elevated erythrocyte sedimentation reaction. Nord Med 1952;48:1193-5.
Bathon J, Graves J, Jens P, Hamrick R, Mayes M The erythrocyte sedimentation rate in end-stage renal failure. Am J Kidney Dis 1987;10:34-40.
Shusterman N, Kimmel PL, Kiechle FL, Williams S, Morrison G, Singer I. Factors influencing erythrocyte sedimentation in patients with chronic renal failure. Arch Intern Med 1985;145:1796-9.
Brouillard M, Reade R, Boulanger E, et al. Erythrocyte sedimentation rate, an underestimated tool in chronic renal failure. Nephrol Dial Transplant 1996;11:2244-7.
Al-Homrany M. The significance of extreme elevation of the erythrocyte sedimentation rate in hemodialysis patients. Saudi J Kidney Dis Transpl 2002;13:141-5.
Yousuf M, Akhter J, Al-Khairy K, Al-Saadan MA, Bin-Salih S. Extremely elevated erythrocyte sedimentation rate: Etiology at a tertiary care center in Saudi Arabia. Saudi Med J 2010;31:1227-31.
Mohammed Ibraheem Alsomaili
Department of Medicine, King Abdulaziz Medical City, Mail Code 1443, P. O. Box 22490, Riyadh 11426
[Table 1], [Table 2], [Table 3]