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Erythrocyte sedimentation rate in renal disease

Alice M Sheridan, MD
Section Editor
Gary C Curhan, MD, ScD
Deputy Editor
John P Forman, MD, MSc


The erythrocyte sedimentation rate (ESR) is elevated (greater than 25 mm/hour by the Westergren method) in almost all patients with the nephrotic syndrome or end-stage renal disease [1-3]. Two-thirds of patients have an ESR above 60 mm/hour, while 20 percent have extreme elevations to above 100 mm/hour, a level usually associated with disorders such as infection, cancer (particularly if metastatic), or collagen vascular diseases such as temporal arteritis [4] (see "Acute phase reactants"). The elevation in ESR is not affected by hemodialysis as the pre- and post-dialysis values are similar [2].

It is likely that plasma factors, particularly increased levels of fibrinogen, and possibly decreased albumin concentration contribute to the elevation in ESR in patients with chronic kidney disease (CKD) [5]. Anemia is known to increase the ESR, although it is not known whether this is an underlying mechanism among CKD patients (see "Acute phase reactants", section on 'Erythrocyte sedimentation rate'). Hypocalcemia does not appear to play a role among CKD patients, and the ESR is not lowered by dialysis. A direct relation between the degree of proteinuria and the ESR has been noted in patients with glomerular disease in which the ESR was approximately 10 times the daily rate of protein excretion [6]. How this might occur is not clear.

The frequent elevation in ESR in renal insufficiency or the nephrotic syndrome is important clinically, because this finding alone is not an indication to evaluate a patient for an underlying systemic disorder. This issue becomes important in a condition such as membranous nephropathy in which a minority of patients has an associated malignancy. Occult malignancy should be excluded if the patient has some suggestive finding such as weight loss, heme-positive stools, or unexplained anemia, but not an isolated increase in ESR. (See "Causes and diagnosis of membranous nephropathy".)

Among patients with renal disease associated with systemic disorders such as systemic lupus erythematosus (SLE), the ESR may correlate with the severity of renal disease [7,8]. However, the ESR is rarely used by nephrologists to monitor activity.


The erythrocyte sedimentation rate (ESR) is elevated in almost all patients with the nephrotic syndrome or end-stage renal disease.

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Literature review current through: Aug 2017. | This topic last updated: Oct 20, 2015.
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