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A comparison of erythrocyte sedimentation rates of bloods anticoagulated with trisodium citrate and EDTA among TB presumptive patients at the University of Gondar comprehensive specialized hospital, northwest Ethiopia



The purpose of this study was comparing the erythrocyte sedimentation rate (ESR) results of trisodium citrate (TSC) and ethylene diamine tetra-acetic acid (EDTA) anticoagulants. A comparative cross-sectional study was conducted at the University of Gondar specialized referral hospital, northwest Ethiopia. A total of 70 TB presumptive participants were recruited. From each of the 70 participants of the study, 3 and 1.6 ml of blood was collected in EDTA tubes and 0.4 ml of trisodium Citrate anticoagulant containing test tubes, respectively.


The mean ± SD values of ESR were 57.9 ± 41.45 mm/h in EDTA and 50.99 ± 43.5 mm/h in TSC anticoagulated blood. The mean difference of ESR values between EDTA and TSC blood (6.91 ± 13.66 mm/h) was statistically significant. The Mean ± SD of ESR values using EDTA and TSC in males were 59.57 ± 42.31 and 53.57 ± 44.61 mm/h while for females it was 54.71 ± 40.44 and 46.04 ± 41.82 mm/h, respectively. The study indicated that there was a significant difference between ESR values with EDTA and TSC anticoagulants.


Erythrocyte sedimentation rate (ESR) is a common inexpensive, sensitive and non-specific hematology test frequently ordered in clinical medicine. It is the most widely used laboratory test for evaluating and monitoring the courses of infections, acute phase inflammation, autoimmune and malignant diseases. In addition, it serves as a general sickness index when it is used in conjunction with patient’s clinical history and physical examinations [1,2,3,4,5,6].

Increased amounts of the plasma proteins, like fibrinogen are the major factors which increase ESR test results by reducing the negative electrostatic force among red blood cells (RBCs), leading to an increased rate of rouleaux formation and the easy falling down of RBCs within plasma [7, 8]. In cases of inflammatory and infectious processes, fibrinogen concentration in the blood increases rouleaux formation and RBCs settle faster than normal [9, 10].

An elevated ESR is often observed in cases of infectious diseases (Tuberculosis (TB), bone and severe skin infections), malignancy, inflammatory or destructive processes, auto immune diseases and rheumatic fever [11,12,13]. As well as in collagen vascular and infective endocarditic diseases [12, 13]. It is also important for the assessment of the severity of inflammatory bowel diseases in children [14,15,16,17] and marking responses to the treatment of TB [18, 19]. Moreover, an increased ESR can be an early predictive marker of HIV seropositive progression towards AIDS [20, 21]. Besides, increased ESR can also be used as an inexpensive “sickness index” in the elderly [22].

A raised result of ESR is observed in a wide range of infectious, inflammatory, generative and malignant conditions and associated occurrences, like anemia, pregnancy, hemoglobinopathies, hemoconcentration and the treatment of anti-inflammatory drugs which change plasma proteins that increase in fibrinogen, immunoglobulin, and C-reactive protein [23, 24].

The principle of the ESR determination is based on the measurements of sedimentation rates of aggregated erythrocytes in plasma. The International Council for Standardization in Hematology (ICSH) recommended the Westergren method as a choice for ESR determination. When anticoagulated blood is placed in a Westergren tube in vertical column, the erythrocytes normally settle quite slowly by the influence of gravity, and the distance of erythrocytes falls down in a vertical column from the plasma in within 1 h will be taken as ESR value [25,26,27].

For ESR determination, blood anticoagulated with 3.8% trisodium citrate (TSC) or ethylene diamine tetra acetic acid (EDTA) can used. Using undiluted blood anticoagulated with K3EDTA is a recommended specimen for ESR determination by ICSH because it gives a more reliable result than the traditional TSC [21, 28] by reducing the risk of pre-analytic mistakes due to a partially coagulated specimen or small clots, an altered blood/trisodium citrate (TSC) ratio, and problems linked to the final volume, inherent mainly in techniques using special tubes for both specimen collection and ESR measurement [25, 26]. However, according to the 2011 ICSH recommendations, the reference method for the measurement of the ESR should be based on the Westergren method with modifications that use either whole blood anticoagulated with EDTA and later diluted with TSC or saline or whole blood anticoagulated with TSC in a 4:1 dilution ratio in Westergren pipettes [29].

Despite the fact that the ESR test is one of the commonest investigations carried out in the clinical hematology laboratories, there has been no recognized standard control sample for monitoring the test. The reliability and reproducibility of the results depends on the use of correct methodologies. Although, a variety of research was conducted on a matters relating to ESR values of different diseases, no attempts were made to compare the ESR values of blood mixed with TSC and EDTA in the study area. So, this study aimed to assess the variability of ESR values of the two commonly used anticoagulants in individuals suffering from presumptive TB.

Main text

Materials and methods

Study setting and population

A comparative cross-sectional study was conducted on a total of 70 study subjects who visited the TB Clinic at the University of Gondar comprehensive specialized hospital (UOGCSH) from March to May 2018. UOGCSH is found in Gondar town, Amhara regional state, northwest Ethiopia. Gondar town is located at 727 km from Addis Ababa and 185 km from Bahir Dar town and situated at a latitude and longitude of 12° 36′ N and 37° 28′ E, respectively, with an elevation of 2133 m above sea level [30] to the north western part of Ethiopia.

All patients aged 15 years and above and willing to participate in the study were included. Patients who did not give enough amounts of blood sample and unwilling to take part were excluded.

Sample size determination

A total of 70 participants were recruited for this comparative cross-sectional study. The double population mean formula was used to calculate the required sample size using the mean and standard deviation (SD) of TSC and EDTA taken from other studies [31] with 80% power (0.84) and 95% level of significance (1.96).

Data collection and ESR determination

The questionnaire and check lists were prepared in the English language and translated to Amharic, the local language, were used to collect socio-demographic and clinical data. Patient blood was collected in K3EDTA tubes (BD Vacutainer® Glass Tubes) and TSC tubes (BD Vacutainer ESR glass tube). Five ml of venous blood was collected from each participant in K3EDTA and TSC tubes. The TSC blood collection tube contained 3.8% of TSC and that of EDTA contained 8.0 mg of EDTA in it. Then 1.6 ml of the whole blood sample was added to the 0.4 ml of 3.8% TSC solution, and 3.0 ml of blood was added to EDTA tube and immediately mixed by inverting the tubes three times. Then ESR values were measured by the Westergren method. For each participant, two tests of ESR determination were performed from each tube within 2 h in accordance with the ICSH recommendation [29]. We filled the Westergren tube to exactly “0” mark and placed the tube in the rack for 1 h, and ESR results were recorded in mm/h. Finally, results obtained from K3EDTA samples were compared to those of TSC samples.

Quality assurance

Standard operating procedures (SOPs) and manufacturers’ instructions were strictly followed for all laboratory activities as much as possible. All blood collection test tubes were checked for expiry dates, and laboratory results were recorded on standard report formats using participant identification number. The data of each patient were reviewed for mislabeling and completeness.

Data analysis

EpiInfo version 3.5.4 was used for data entry and SPSS version 20 for analysis. In this study, we used the paired t-test to determine significant differences between whole blood anticoagulated using EDTA and TSC for ESR determination. The mean was used since it is the basis for all statistical computations, and SD was obtained to aid the computation of the t-value to measure the average amount of scatter in a distribution. To establish the relationship between the 2 methods, comparison studies were analyzed by simple least squares linear regression and Pearson’s correlation coefficient to obtain the y-intercept, the slope, and the SD of the regression line (Sy/x). The data were compared by the Bland–Altman analysis [32]. Paired sample t-test at 95% confidence level was used to compare the two methods, and in all cases P-values < 0.05 were considered as statistically significant.


Socio-demographic information

A total of 70 TB presumptive patients aged from 15 to 82 years were included in the study. The majority, 46 (65.7%), of the participants were male and lived in rural areas; 21 (30%) were in the age range of 36–50 years (Table 1).

Table 1 Socio-demographic information of the study participants (N = 70)

Comparison of ESR values

The Mean ± SD ESR values of patients according to EDTA and TSC anticoagulated blood were 57.9 ± 41.45 and 50.99 ± 43.5 mm/h, respectively. The ESRs value obtained from EDTA blood were higher than TSC blood for all independent variables. The mean ± SD of ESR value in males using EDTA and TSC blood was 59.57 ± 42.31 and 54.71 ± 40.44 mm/h while for females it was 53.57 ± 44.61 and 46.04 ± 41.82 mm/h (Table 2).

Table 2 Paired t-test comparing the Mean ± SD ESR values of the study participants using EDTA and TSC Whole Blood

The paired sample t-test analysis showed that there was a statistically significant difference between the mean ± SD of ESR values of the two anticoagulated blood. The mean difference of ESR values between the use of EDTA and TSC anticoagulated blood was 6.91 ± 13.66 mm/h with a t-value of 4.24 (P < 0.0001; 95% CI 3.66–10.17). The computed t-value (4.24) was greater than the tabulated or critical t-value (1.667) at 69 degree of freedom and 95% level of significance. Therefore, there was a significant difference between the use of EDTA and TSC as anticoagulants for ESR determination (Additional file 1: Table S1).

The Bland–Altman data analysis showed no systematic bias, and 95% of all samples fell into the narrow 95% limits of agreement (d − 1.96 SD = 6.914–[1.96 × 13.661] = − 19.9 and d + 1.96 SD = 6.914 + [1.96 × 13.661] = + 33.7) (Fig. 1). A linear regression analysis showed a satisfactory correlation between the two methods (r = 0.949, P < 0.001; r2 = 0.901; y = 11.769 + 0.949x; and Sy/x = 13.106) (Additional file 2: Figure S1).

Fig. 1

Bland–Altman plot of ESR values from the EDTA and the TSC whole blood using manual Westergren method


Although ESR is not a specific marker of inflammation, currently it is frequently used in the diagnosis and evaluation or monitoring of patients with chronic diseases [33]. The ESR value obtained from this comparison showed that the mean value of EDTA anticoagulated blood (57.90 mm/h) was greater than that of TSC blood (50.99 mm/h) by 6.91 mm/h. This may be because EDTA increases rouleaux formation more than TSC, leading to increases in ESR in EDTA blood, or it might be due to a difference in viscosity, where citrated blood may be less viscous than EDTA blood resulting in lower ESR values [34,35,36]. This observation corresponds to the result reported from Tehran University, Iran, and stated that there was a significant difference between the results of ESR tests which used two anticoagulants [37].

The result of our study was similar to that of a study conducted in Nigeria whose final finding stated that the mean ± SD ESR value of EDTA anticoagulated blood was higher than the mean ± SD ESR value of the TSC. When compared to our finding, the result of the Nigerian study was within the normal range of ESR. The reason for the difference was that their study was conducted on healthy individuals, while ours was conducted on presumed TB patients which increased the ESR value. In addition, the mean ± SD ESR values of males were less than those of females, contradicting the finding. This might be due to the fact that most of our male participants were old and had history of TB [31].

However, the result of our study differed from what was reported in India and stated that ESR measurement values of citrated blood were greater by 4–6 mm/h than those of EDTA [10]. Our result also differed from that of a study conducted at Yenepoya University hospital, India. They found that the values of ESR that utilized EDTA was 4–6 mm/h less than values that used TSC. The authors recommended that ESR be performed using EDTA blood instead of TSC since the former utilizes only a limited amount of blood for the procedure [9]. Another study done in the Philippines found a mean ESR value of 36.7 and 43.09 for EDTA and TSC, respectively. These differed from our findings, perhaps because of some physiological and genetic differences between white and black people [38].


The average ESR value among participants of UoGCSH using EDTA and TSC blood were 57.90 and 50.99, respectively. The ESR value of EDTA anticoagulated blood was greater than that of TSC blood with a mean difference of 6.91. The computed t-value (4.2.) is greater than the tabulated t-value therefore there is a significant difference between the use of EDTA and TSC as anticoagulant for ESR determination. Therefore, laboratories using EDTA and TSC for ESR determination should have different reference values for each anticoagulant if the observed findings are confirmed in healthy population and among sick individuals.


The study was not only limited to a single district but also dealt with just presumed TB patients. Therefore, the result of this research may not be representative for the whole population.

Availability of data and materials

All the data on which the conclusions of this manuscript are drawn are available in the corresponding author. So that any who needs the data can get it upon reasonable request.



Complete blood count


Ethylene diamine tetra acetic acid


Erythrocyte sedimentation rate


University of Gondar Comprehensive Specialized Hospital


International Council for Standardization in Hematology


Tri potassium ethylene diamine tetra acetic acid


millimeter per hour


National committee for clinical laboratory standard


Red blood cells


Standard deviation




Trisodium citrate


  1. 1.

    Mahlangu JN, Davids M. Three-way comparison of methods for the measurement of the erythrocyte sedimentation rate. J Clin Lab Anal. 2008;22(5):346–52.

    Article  Google Scholar 

  2. 2.

    Ozdem S, Akbas HS, Donmez L, Gultekin M. Comparison of TEST 1 with SRS 100 and ICSH reference method for the measurement of the length of sedimentation reaction in blood. Clin Chem Lab Med. 2006;44(4):407–12.

    CAS  Article  Google Scholar 

  3. 3.

    Musa RJ, Mansoor SS, Ali HH. Westergren Sedimentation Rate using K3EDTA. Iran J Med Sci. 2004;3(2):132–5.

    Google Scholar 

  4. 4.

    Salehzadeh F, Noshin A, Jahangiri S. IVIG effects on erythrocyte sedimentation rate in children. Int J Pediatr. 2014;2014:981465.

    Article  Google Scholar 

  5. 5.

    Hoffbrand AV, Moss PA. Essential haematology. 6th ed. West Sussex: Wiley; 2011.

    Google Scholar 

  6. 6.

    Dewi MMW, Herawati S, Mulyantari NK, Prabawa IPY. The comparison of erythrocyte sedimentation rate (ESR) modify Westergren Caretium Xc-A30 and Westergren Manual in Clinical Pathology Laboratory, Sanglah General Hospital, Denpasar, Bali. Bali Med J. 2019;8(2):396–9.

    Google Scholar 

  7. 7.

    American Society for Clinical Pathology/American Proficiency Institute. Educational Commentary. The Erythrocyte Sedimentation Rate and its Clinical Utility. 2nd Test Event, 2006. Accessed Dec 20 2019.

  8. 8.

    Mack DR, Langton C, Markowitz J, LeLeiko N, Griffiths A, Bousvaros A, et al. Laboratory values for children with newly diagnosed inflammatory bowel disease. Pediatrics. 2007;119(6):1113–9.

    Article  Google Scholar 

  9. 9.

    Kumta S, Nayak G, Kedilaya HP, Shantaram M. A comparative study of erythrocyte sedimentation rate (ESR) using sodium citrate and EDTA. Int J Pharm Biol Sci. 2011;1(4):393–6.

    CAS  Google Scholar 

  10. 10.

    Brigden M. The erythrocyte sedimentation rate: still a helpful test when used judiciously. Postgrad Med. 1998;103(5):257–74.

    CAS  Article  Google Scholar 

  11. 11.

    Go DJ, Lee EY, Lee EB, Song YW, Konig MF, Park JK. Elevated erythrocyte sedimentation rate is predictive of interstitial lung disease and mortality in dermatomyositis: a korean retrospective cohort study. J Korean Med Sci. 2016;31(3):389–96.

    CAS  Article  Google Scholar 

  12. 12.

    Saadeh C. The erythrocyte sedimentation rate: old and new clinical applications. South Med Birm Ala. 1998;91:219–26.

    Article  Google Scholar 

  13. 13.

    Brigden ML. Clinical utility of the erythrocyte sedimentation rate. Am Fam Physician. 1999;60(5):1443–50.

    CAS  Google Scholar 

  14. 14.

    Bain B. Some influences on the ESR and the fibrinogen level in healthy subjects. Clin Lab Haematol. 1983;5(1):45–54.

    CAS  Article  Google Scholar 

  15. 15.

    Zlonis M. The mystique of the erythrocyte sedimentation rate: a reappraisal of one of the oldest laboratory tests still in use. Clin Lab Med. 1993;13(4):787–800.

    CAS  Article  Google Scholar 

  16. 16.

    Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation. N Engl J Med. 1999;340(6):448–54.

    CAS  Article  Google Scholar 

  17. 17.

    Fabry TL. Mechanism of erythrocyte aggregation and sedimentation. Blood. 1987;70(5):1572–6.

    CAS  Article  Google Scholar 

  18. 18.

    Mahalakshamamma V, Raju E, Jhansi K. Erythrocyte sedimentation rate values in pulmonary tuberculosis versus normal healthy peoples in Khammam region of Telangana, India. Int J Integr Med Sci. 2016;3:207–10.

    Article  Google Scholar 

  19. 19.

    Mandal SK, Chavan L. Erythrocyte sedimentation rate values in cases of active tuberculosis without HIV co-infection. J Med Sci Clin Res. 2016;4(10):13156–9.

    Article  Google Scholar 

  20. 20.

    Lefrere J, Salmon D, Doinel C, Rouger P, Courouce A, Lambin P, et al. Sedimentation rate as a predictive marker in HIV infection. AIDS. 1988;2(1):63.

    CAS  Article  Google Scholar 

  21. 21.

    Foromera J. Diagnostic and Prognostic Value of ESR and CRP in HIV Positive Adults in Durban, South Africa. Doctoral dissertation, Harvard Medical School. 2017 .

  22. 22.

    Wolfe F, Michaud K. The clinical and research significance of the erythrocyte sedimentation rate. J Rheumatol. 1994;21(7):1227–37.

    CAS  Google Scholar 

  23. 23.

    Cheesbrough M. District laboratory practice in tropical countries. Cambridge: Cambridge University Press; 2006.

    Google Scholar 

  24. 24.

    Thue G, Sandberg S, Fugelli P. The erythrocyte sedimentation rate in general practice: clinical assessment based on case histories. Scand J Clin Lab Invest. 1994;54(4):291–300.

    CAS  Article  Google Scholar 

  25. 25.

    Horsti J, Kovanen M. Using EDTA as an anticoagulant for ESR to replace citrate. Kliin lab. 2000;4:97–100.

    Google Scholar 

  26. 26.

    Koepke J, Van Assendelft O, Bull B, Richardson-Jones A. Standardization of EDTA anticoagulation for blood counting procedures. Labmedica. 1988;1989:5.

    Google Scholar 

  27. 27.

    International Council for Standardization in Haematology. ICSH recommendation for measurement of erythrocyte sedimentation rate. J Clin Pathol. 1993;46:198–203.

    Article  Google Scholar 

  28. 28.

    National Committee for Clinical Laboratory Standards. Reference and selected procedure for erythrocyte sedimentation rate (ESR) test; approved standard. 4th ed. Villanova: NCCLS; 2000.

    Google Scholar 

  29. 29.

    Jou J, Lewis S, Briggs C, Lee SH, De La Salle B, McFadden S, et al. ICSH review of the measurement of the erythrocyte sedimentation rate. Int J Lab Hematol. 2011;33(2):125–32.

    CAS  Article  Google Scholar 

  30. 30.

    Central Statistical Agency. Summary and statistical report of the 2007 population and housing census: population size by age and sex. Addis Ababa: Central Statistical Agency; 2008.

    Google Scholar 

  31. 31.

    Emelike O, Akpan J, Obigwe B, Jeremiah Z. Comparative study of erythrocyte sedimentation rate (ESR) using trisodium citrate, normal saline and whole blood in ethylene di amine tetra acetic acid (EDTA). J Appl Sci Environ Manag. 2010;14(1):23–7.

    CAS  Google Scholar 

  32. 32.

    Altman DG, Bland JM. Assessing agreement between methods of measurement. Clin Chem. 2017;63(10):1653–4.

    Article  Google Scholar 

  33. 33.

    Fischbach FT, Dunning MB III. A manual of laboratory and diagnostic test. 9th ed. Philadelphia: Philadelphia Wolters Kluwer Health and Lippincott Williams & Wilkins; 2015.

    Google Scholar 

  34. 34.

    Lawrence JS. Assessment of the activity of disease. London: H. K. Lewis & Co., Ltd.; 1961. p. 31–56.

    Google Scholar 

  35. 35.

    Hardwicke J, Squire J. The basis of the erythrocyte sedimentation rate. Clin Sci. 1952;11(4):333.

    CAS  Google Scholar 

  36. 36.

    Furukawa K, Abumiya T, Sakai K, Hirano M, Osanai T, Shichinohe H, et al. Increased blood viscosity in ischemic stroke patients with small artery occlusion measured by an electromagnetic spinning sphere viscometer. J Stroke Cerebrovasc Dis. 2016;25(11):2762–9.

    Article  Google Scholar 

  37. 37.

    Maghsood R, Geransar A, Jahanzad E, Jahanzad L. A comparative study on the effect of sodium citrate and EDTA in ESR after one and two hours in children and adults, Tehran University of Medical Sciences. IJP. 2005;15(2):125–31.

    Google Scholar 

  38. 38.

    Simtoco DMJ, Enricuso CF, Gonzaga WJ, Cabrera NL, Tria MT. Comparison of ESR among patients of Cebu doctors’ hospital using EDTA and citrated blood, at Cebu Doctors’ Hospital Laboratory. Thesis. Cebu Doctors’ University, 1998.

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The authors would like to acknowledge the study participants, University of Gondar hospital TB clinic and Laboratory staffs for their collaboration. We would also thank to the University of Gondar, College of Medicine and Health Sciences, School of Biomedical and Laboratory Sciences for all the supports and collaborations in general.


The author(s) received no specific funding for this work.

Author information




ZG, FA, GA and HG were participated in designing the study, supervised the data collection, analyzed, interpret and write up the manuscript. FA, GA, HG, AY and TM were involved in proposal development, data collection and entry of data for analysis. TM and ZG are the joint first authors of the paper. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Zegeye Getaneh.

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Ethics approval and consent to participate

Ethical clearance was obtained from University of Gondar, School of Biomedical and Laboratory Sciences Research and Ethical Review Committee. Permission letter was obtained from the hospital director to conduct the study. The objectives of the research were explained to the study participants and written informed consent was taken. To ensure confidentiality of data, participants were identified using codes.

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Not applicable.

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The authors declare that there is no any conflict of interest regarding the publication of this work.

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Supplementary information

Additional file 1: Table S1.

Paired Samples t-test of the ESR values of the study participant using EDA and TSC whole blood.

Additional file 2: Figure S1.

Comparison of the ESR values from the EDTA and TSC whole blood using manual Westergren method by regression analysis (r = 0.949, P = 0.001).

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Getaneh, Z., Ayelgn, F., Asemahegn, G. et al. A comparison of erythrocyte sedimentation rates of bloods anticoagulated with trisodium citrate and EDTA among TB presumptive patients at the University of Gondar comprehensive specialized hospital, northwest Ethiopia. BMC Res Notes 13, 113 (2020).

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  • Erythrocyte sedimentation rate
  • EDTA
  • Tri-sodium citrate
  • Westergren method
  • Comparison