Agreement between Erythrocyte Sedimentation Rate and C-Reactive Protein in Hospital Practice

doi:10.1016/j.amjmed.2010.04.021

The American Journal of Medicine

Volume 123, Issue 9, September 2010, Pages 863.e7-863.e13

https://doi.org/10.1016/j.amjmed.2010.04.021 Get rights and content

Abstract

Background

Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are frequently prescribed jointly. The usefulness of this practice is uncertain.

Methods

All patients with ESR and CRP measured at the same time in an academic tertiary hospital during a 1-year period were included. Concomitant measures of serum creatinine, hematocrit, and anti-Xa activity were recorded to study noninflammatory cause of increased ESR. Level of agreement between ESR and CRP was assessed with kappa coefficient, and their accuracy was determined in a medical chart review of 99 randomly selected patients with disagreement between both markers.

Results

Among 5777 patients, 35% and 58% had an elevated CRP and ESR, respectively. ESR and CRP were in agreement in 67% of patients (both elevated in 30%, both normal in 37%). A disagreement was observed in 33% (elevated ESR/normal CRP in 28%, normal ESR/elevated CRP in 5%). The kappa coefficient showed poor agreement (k = 0.38) between both markers. Review of medical chart showed that 25 patients with elevated CRP and normal ESR had an active inflammatory disease (false-negative ESR). Conversely, 74 patients had elevated ESR and normal CRP—32% had resolving inflammatory disorders, 28% disclosed a variable interfering with the ESR measure (false-positive ESR), 32% had unexplained discrepancies, and 8% had an active inflammatory disease (false-negative CRP).

Conclusion

In hospital practice, joint measurement of ESR and CRP is unwarranted. Because of slow variation and frequent confounding, ESR is frequently misleading in unselected patients. When an inflammatory disorder is suspected, priority should be given to CRP.

Section snippets

Study Design

Georges Pompidou European Hospital is a tertiary care university hospital in Paris with 850 acute care beds. Its comprehensive computerized clinical information system is patient centered with an electronic health record, a complete cycle of laboratory tests ordering, and results delivery. All laboratory test results, imaging reports, hospital medical and nursing reports, and diagnosis at discharge are available in hospital databases identified by patients and dates of hospitalization.

Results

During 1 calendar year, 5777 patients (mean age: 61.3 ± 19.1 years) referred to Georges Pompidou European Hospital had 9581 concomitant ESR and CRP measurements. These concomitant measurements corresponded to 76% of all ESR measurements and 12% of all CRP measurements. Most patients were hospitalized in medical units (Figure 1): internal and geriatric medicine (45%), cardiovascular medicine (22%), gastroenterology and liver diseases (8%), respiratory diseases (7%), surgery (6%), others (5%),

Discussion

In this large retrospective study, ESR was elevated in 58% of 5777 patients, and CRP was elevated in 35% of patients. Both markers were elevated in 30% of cases. The overall agreement was poor (kappa = 0.38) and even lower in patients with anemia and renal failure. The review of a randomly selected sample of medical charts of patients with discordant results showed that ESR was more commonly inaccurate (92% vs 8%).

Five studies previously assessed the relevance of concomitant ESR and CRP

Conclusions

We showed that the interpretation of ESR is frequently spurious because of common associated conditions that influence its measure. This suggests that priority should be given to CRP measure. Concomitant measures of ESR and CRP should be avoided; assessment of discordant results may incur substantial costs and could even place patients at risk for invasive procedures.

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The clinical application of the erythrocyte sedimentation rate (ESR) assay is challenging due to its long processing time. However, in 2020 a new automated instrument for veterinary ESR was released and validated. This study sought: (1) to refine the proposed reference range (reference interval, RI) for canine ESR; (2) to compare the ESR values of healthy and sick dogs; and (3) to correlate ESR with other inflammatory markers such as C-reactive protein (CRP), fibrinogen, albumin:globulin ratio (A/G), and neutrophil-to-lymphocyte ratio (NLR); and also (4) to study ESR behavior across illnesses of varying durations. A prospective cohort study of 396 client-owned dogs (n = 120 healthy and n = 276 sick dogs) was conducted. Animals with a full clinical evaluation, complete hematobiochemical profile and a final diagnosis were included. ESR was performed according to manufacturer’s instructions using the same 1 mL K3-EDTA tube used for the complete blood count.
The RI was established at 1–8 mm/h in 14 min. Sick dogs had a significantly faster ESR (median 10 mm/h) than healthy dogs (median 1 mm/h; P < 0.0001). ESR was positively correlated with NLR (r = 0.36), CRP (r = 0.18) and fibrinogen (r = 0.56) and negatively correlated with A/G (r = −0.37). Dogs with an acute-on-chronic disease had the highest ESR values (median 17 mm/h) compared with either acute (median 11 mm/h; P < 0.001) or chronic diseases (median 7 mm/h; P = 0.001). ESR was confirmed as a reliable canine inflammatory marker, positively correlating with the main inflammatory markers in dogs and significantly different between sick and healthy dogs. The ESR assay appears useful especially in dogs with an acute clinical presentation, with or without an underlying chronic condition.
Discrepancies between erythrocyte sedimentation rate and C-reactive protein in non-infectious inflammatory diseases
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Impact of an electronic decision support rule on ESR/CRP co-ordering rates in a community health system and projected impact in the tertiary care setting and a commercially insured population
2019, Clinical Biochemistry
Citation Excerpt :
Discordant ESR elevations may be attributed to recently resolved inflammation (as ESR normalizes more slowly than CRP) or other factors including: paraproteinemia, hypoalbuminemia, anemia, macrocytosis, ischemic stroke, malignancy, and renal insufficiency [4,19]. Previous studies have shown that only 8% of ESR elevations in the setting of a normal CRP are due to active inflammation; thus, the vast majority of these instances represent a false positive ESR result [10]. Therefore, ESR testing in most of these clinical scenarios represents laboratory testing waste that should be curtailed through utilization management efforts.
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are common laboratory assays used as markers of inflammation. ESR suffers from higher false positive and false negative rates than CRP. To that end, the American Board of Internal Medicine's (ABIM's) Choosing Wisely campaign has recommended against ESR testing for those with undiagnosed conditions in favor of CRP testing. This study describes the impact of a computerized provider order entry (CPOE) decision support rule against ESR/CRP co-ordering within a community health system that predates the ABIM's Choosing Wisely national guidance. To demonstrate the potential impact of such a CPOE rule within other healthcare settings, ESR/CRP ordering data from a multi-site tertiary care practice and from the commercially insured population in the OptumLabs® Data Warehouse (OLDW) were analyzed and the relative reduction in ESR/CRP co-ordering achieved within the community health system was projected onto these populations.
ESR and/or CRP orders from a community health system were assessed from 2012 to 2016. Co-ordering and test concordance rates between ESR and CRP were compared before and after CPOE decision support rule launch. Similarly, ESR/CRP co-ordering across three tertiary care sites from 2015 to 2016 and the OLDW from 2009 to 2013 were assessed and the co-ordering rate reduction achieved in the community health system was mathematically projected onto these populations. Estimated payer savings from the rule's effect were calculated within each population using Medicare reimbursement rates.
The CPOE decision support rule realized an unadjusted 42% relative rate reduction in ESR/CRP co-ordering within the community health system yielding an annual payer savings of $15,000 with a modest increase in ESR/CRP concordance rates. Projecting a 40% relative reduction in ESR/CRP co-ordering rates from a similarly effective CPOE rule, annual payer cost reductions exceeding $100,000 within a multi-site tertiary care setting and $1,000,000 within the OLDW would be expected.
ESR/CRP co-ordering represents an opportunity to eliminate testing waste and reduce payer costs. A CPOE decision support rule stably reduces ESR/CRP co-ordering rates. Similar results may occur as one component of new commercially available decision support platforms.
Manual, semiautomated, and point-of-care testing in hematology
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Les études comparant les profils inflammatoires systémiques des fumeurs atteints et indemnes de BPCO présentent des conclusions discordantes.
Comparer le profil inflammatoire systémique des fumeurs atteints de BPCO avec ceux indemnes de BPCO.
Il s’agit d’une étude prospective de type comparative incluant deux groupes de fumeurs actifs de plus de 10 paquets-années et cliniquement stables : 56 BPCO consécutifs (VEMS/CVF postbronchodilatateur < 0,70) et 32 fumeurs consécutifs non BPCO (VEMS/CVF postbronchodilatateur ≥ 0,70). Le tabagisme et les données cliniques, anthropométriques et spirométriques ont été notés. Les marqueurs biologiques sanguins suivants ont été déterminés : leucocytes, hémoglobine, facteur de nécrose tumorale-α (TNF-α), interleukine-6 (IL-6), protéine C réactive (CRP) et vitesse de sédimentation (VS). Selon les taux (normaux/anormaux) de ces marqueurs, deux groupes de fumeurs ont été formés. Les variables quantitatives et qualitatives ont été exprimées, respectivement, en moyennes ± écart-types et en pourcentages.
Comparativement au groupe non BPCO, le groupe BPCO était plus âgé (56 ± 12 contre 65 ± 8 ans) et avait une consommation de tabac plus élevée (30 ± 18 contre 52 ± 31 paquets-années). Comparativement au groupe non BPCO, le groupe BPCO avait des valeurs plus élevées de CRP (2,06 ± 1,24 contre 11,32 ± 11,03 mg/L), de VS (9,59 ± 8,29 contre 15,96 ± 11,56), d’IL-6 (9,28 ± 4,69 contre 20,27 ± 5,31 ng/L) et de TNF-α (18,38 ± 7,98 ng/L contre 8,62 ± 3,72 ng/L). Comparativement au groupe non BPCO, le groupe BPCO incluait des pourcentages plus élevés de fumeurs ayant une CRP élevée (0 % contre 32 %), une hyperleucocytose (6 % contre 16 %), des taux élevés d’IL-6 (81 % contre 98 %) ou de TNF-α (91 % contre 100 %).
Les fumeurs BPCO, comparés aux non-BPCO, ont une inflammation systémique plus marquée.
Studies comparing the systemic inflammatory profiles of smokers with and without COPD present discordant findings.
To compare the systemic inflammatory profile of smokers with and without COPD.
This is a cross-sectional comparative study. Two groups of active smokers of more than 10 pack-years were included: 56 consecutives stable COPD (postbronchodilator FEV₁/FVC < 0.70) and 32 consecutives non-COPD (postbronchodilator FEV₁/FVC ≥ 0.70). Smoking and clinical, anthropometric and spirometric data were noted. The following blood biomarkers were identified: leukocytes, hemoglobin, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR). According to the levels (normal/abnormal) of these markers, two groups of smokers were formed. Quantitative and qualitative data were expressed, respectively, as means ± SD and percentages.
Compared to the non-COPD group, the COPD group was older (56 ± 12 vs. 65 ± 8 years) and had a higher smoking consumption (30 ± 18 vs. 52 ± 31 pack-years). Compared to the non-COPD group, the COPD group had higher values of CRP (2.06 ± 1.24 vs. 11.32 ± 11.03 mg/L), of ESR (9.59 ± 8.29 vs. 15.96 ± 11.56), of IL-6 (9.28 ± 4.69 vs. 20.27 ± 5.31 ng/L) and of TNF-α (18.38 ± 7.98 ng/L vs. 8.62 ± 3.72 ng/L). Compared to the non-COPD group, the COPD group included higher percentages of smokers with elevated CRP (0 % vs. 32 %), with leukocytosis (6 % vs. 16 %), with higher levels of IL-6 (81 % vs. 98 %) or TNF-α (91 % vs. 100 %).
Smokers with COPD, compared to smokers free from COPD, have a marked systemic inflammation.

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: Funding: None.

: Conflict of Interest: The authors state that they have no conflict of interest regarding the content of the article.

: Authorship: All authors had access to the data and played a role in writing this manuscript.

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AJM onlineClinical research studyAgreement between Erythrocyte Sedimentation Rate and C-Reactive Protein in Hospital Practice

Abstract

Background

Methods

Results

Conclusion

Section snippets

Study Design

Results

Discussion

Conclusions

Am J Med Sci

Am J Med

J Clin Epidemiol

Acute-phase proteins and other systemic responses to inflammation

N Engl J Med

Guidelines on selection of laboratory tests for monitoring the acute phase responseInternational Committee for Standardization in Haematology (expert panel on blood rheology)

J Clin Pathol

C-reactive protein: a critical update

J Clin Invest

Why shouldn't we determine the erythrocyte sedimentation rate?

Clin Infect Dis

The erythrocyte sedimentation rateGuidelines for rational use

Ann Intern Med

Simple rule for calculating normal erythrocyte sedimentation rate

Br J Med

Normal erythrocyte sedimentation rate and age

Br Med J

Erythrocyte sedimentation rate in a population of 47,205 adultsVariation with age

Rev Rhum Mal Osteoartic

Normal erythrocyte sedimentation rate in the elderly

Br Med J (Clin Res Ed)

AJM online
Clinical research study
Agreement between Erythrocyte Sedimentation Rate and C-Reactive Protein in Hospital Practice