EXAMPLE LETTER
Benson Viscometers Ltd 10/09
NHS Letter Head
The Hospital
Haematology Department
High Road
New Town
XX1 2YY
Tel:
Fax:
Email:
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Date
FAO Practice Medical Staff
Dear Colleagues
The Haematology Department is upgrading its service. This includes changing one of its tests
frequently requested by general practitioners.
ESR will be replaced by the Plasma Viscosity test (PV). PV analysis removes some of the nonclinical variables associated with the ESR and therefore gives an improved result for diagnosis and
monitoring of patients with chronic inflammatory disease. PV analysis is undertaken from the
routine EDTA (purple top) full blood count tube, so no new or additional tube is required.
With the exception of clinical trials or specific patient testing, the laboratory will cease to use ESR
tests from 30th September 2009.
Apart from small stocks, any outstanding ESR tubes should be returned to the laboratory.
Enclosed are some general guidelines on the clinical use of PV along with a comparison to ESR
results in detecting and monitoring chronic disease.
If having read the document you have any specific questions; please contact me directly on the
above telephone number or by e-mail.
Yours sincerely
EXAMPLE LETTER
Dr ABC
Consultant Haematologist and Laboratory Director.
Enc:
Benson Viscometers Ltd 10/09
EXAMPLE LETTER
Benson Viscometers Ltd 10/09
PROPOSAL TO REPLACE ESR WITH PLASMA VISCOSITY
Background
Both plasma viscosity and ESR are used to monitor the acute phase response to screen for the
presence of infection or inflammation and to monitor disease activity but there are significant
differences between each test.
The Haematology Laboratory has reviewed its repertoire of tests and proposes to replace ESR
measurements with measurements of plasma viscosity (PV). The case for change, both from a
clinical and technical aspect, is made below.
SAMPLE REQUIREMENTS
A standard FBC sample (EDTA) is required for PV measurement. FBC and PV can be carried out
on the same sample; no additional sample is required. PV is stable at room temperature for up to 1
week post sampling.
INTERPRETATION OF RESULTS
Normal Range
1.50 1.72 mPa.s
Low results
<1.50
Found in infants under 3 years old and patients with low
immunoglobulin or fibrinogen levels.
High results
1.75 2.00
Found in many chronic disorders e.g. Autoimmune and
rheumatic diseases infection, malignancy, vascular disease and
other causes of inflammation.
Very high results
2.01 3.00
Suggestive of myeloma.
Extremely high
results
>3.00
Suggestive of Waldenstroms macroglobulinaemia.
PHYSIOLOGICAL FACTORS INFLUENCING PLASMA VISCOSITY
Age (after 3 years), gender, and diurnal rhythms have no effect on PV. Throughout life serial PV
measurements in a healthy individual vary as little as 0.05 mPa.s. The only physiological factor that
has a significant and consistent effect on PV is pregnancy. PV remains normal in the first two
trimesters and gradually rises to around 1.80 mPa.s in the final trimester.
Small variations in PV may be clinically significant.
EXAMPLE LETTER
Benson Viscometers Ltd 10/09
PLASMA VISCOSITY IN DISEASE
Acute phase response
As a result of the acute phase response many plasma proteins including fibrinogen and
immunoglobulins are increased and this is reflected in a rise in PV. This response occurs
within 2-24 hours.
Chronic inflammatory diseases
Like the ESR, PV cannot diagnose any condition. However, when taken in conjunction with
a clinical assessment a result in the range of 1.75 2.00 mPa.s can give a good indication of
an underlying problem. ESRs and PVs are affected by different factors and are not always
equivalent (see Tables). Studies have shown PV to be equal or superior to the ESR in
monitoring of patients with rheumatoid arthritis and in the diagnosis of temporal arteritis.
While anaemia and the age of the sample can affect the ESR with no change in the
underlying condition, serial PV assessments will quite accurately reflect the progress of the
condition as they are not influenced by these factors.
Malignant disease
Early stage malignancy can be associated with a normal PV. With more advanced disease
there is often a moderate rise in PV.
Paraproteinaemias
This group of disorders can be associated with markedly raised PVs and such patients may
display symptoms of hyperviscosity (confusion, visual disturbance, epistaxis, difficulty
breathing, renal impairment). In general, IgM paraproteins are associated with much higher
PVs than IgG and IgA paraproteins, but this cannot be assumed or inferred because some
IgG and IgA molecules polymerize and lead to very high PVs.
NB: a normal PV, just the same as a normal ESR, does not exclude a diagnosis of light chain
only or non-secretary myeloma.
Severely ill patients
In severely ill patients (e.g. in intensive care) impaired synthesis and/or increased
degradation of plasma proteins may lead to a fall in PV. This should not be taken as an
indication of an improvement in the patients underlying condition in this situation.
EXAMPLE LETTER
Benson Viscometers Ltd 10/09
Comparison of PV and ESR: clinical aspects
Plasma viscosity
ESR
Normal range the same for both sexes
Normal range different for both sexes
Unaffected by physiological stimuli
(except in pregnancy)
Influenced by age and haematocrit
(Red cell concentration)
Increased result due to change in protein
concentration
(mainly fibrinogen and/or globulins)
No exact cause can be stated for increase in ESR
(Changes in Red cell shape/concentration and
protein changes)
Abnormal results detected earlier
Abnormal results detected later
Low incidence of false negative results
High incidence of false negative results
Serial tests in an individual responding to therapy
would show a fall in PV on a continuous curve
ESR results show irregular peaks and troughs
without clinical explanation
High dose steroids do not normalise the PV.
(Inflammation must be reduced)
High dose steroids will return ESR to normal.
(Underlying disease may not be improved)
Salicylates have no effect on PV
Salicylates can lower the ESR result without
improving the underlying condition of the patient
Polycythaemia does not interfere with
measurements
Haematocrit >50% will produce a normal ESR
irrespective of the underlying disease
Results in myeloma and macroglobulinaemia are
characteristic and can be diagnostic
ESR cannot distinguish between protein
abnormalities and inflammatory conditions
Comparison of PV and ESR: technical aspects
Plasma viscosity
Unaffected by time-induced deterioration and can
be analysed up to 1 week post sampling
Unaffected by anaemia
Variations in red cell size and shape have no effect
All results are universally comparable.
Calibration using fully traceable, CE marked
reagents
External Independent Quality Control is available
(Central Quality Assurance Scheme QEH.
Birmingham UK.)
Time factor: from receipt of sample,
centrifugation and testing takes 10 minutes if lab
is notified in advance
ESR
Must be analysed within 4 hours of sampling
unless EDTA sample, which has a 24 hour time
limit
Affected by anaemia
Red cell size and shape variations affect the rate of
sedimentation
Results not universally comparable due to
different anticoagulants, tubes and timing
methods.
No Independent Quality Control possible.
Time factor: from receipt of sample, setting up and
reading of result takes 65 minutes
EXAMPLE LETTER
Benson Viscometers Ltd 10/09
REFERENCES
1. G. D. O. Lowe. Should Plasma Viscosity Replace the ESR? : British Journal of Haematology,
1994; 86, 6-11.
2. Orrell R W & Johnson M H (1993). Plasma viscosity and the diagnosis of giant cell arteritis. Br.
J. Clin. Pract. 47(2):71-2
3. Gudmundsson M, E. Nordborg, B-A, Bengtsson, A, Bjelle. Plasma Viscosity in Giant Cell
Arteritis as a Predictor of Disease Activity: Annals of the Rheumatic Diseases 1993; 52: 104-109.
4. Gudmundsson M & Bjelle A (1995). Plasma viscosity in the monitoring of therapy in
rheumatoid arthritis patients. Scand. J. Rheumatol. 24(4):219-24.
5. International Committee for Standardization in Haematology (Expert panel on Rheology).
Guidelines on selection of laboratory tests for monitoring the acute phase response: Journal of
Clinical Pathology, 1988; 41: 1203-1212
6. T. Ng. Erythrocyte Sedimentation Rate, Plasma Viscosity and C-Reactive Protein in clinical
Practice: British Journal of Hospital Medicine 1997; 58: 521-523.
7. H. A. Bird, W. Esselinckx, A. S. Dixon, et al. An Evaluation of Criteria for Polymyalgia
Rheumatica: Annals of the Rheumatic Diseases 1979; 38: 434-439.
8. G. P. H. Brittain, G. G. Mcilwaine, J. A. Bell, J. M. Gibson. Plasma Viscosity or Erythrocyte
Sedimentation Rate in the Diagnosis of Giant Cell Arteritis: British Journal of Ophthalmology
1991; 75: 656-659.
9. G. D. O. Lowe. Blood Rheology, Haemostasis and vascular disease: Haemostsis and
Thrombosis ,3rd edition (edited by A. L. Bloom, C. D. Forbes, D. P. Thomas and E. G. D.
Tuddenham); 1169-1188. Caryl Churchill Livingstone Edinburgh.
10. Paulus H E et al. (1999). Equivalence of the acute phase reactants C-reactive protein, plasma
viscosity, and Westergren erythrocyte sedimentation rate when used to calculate American College
of Rheumatology 20% improvement criteria or the disease activity Score in patients with early
rheumatoid arthritis. Western Consortium of Practicing Rheumatologists. J.Rheumatol.
26(11):2324-31.
11. Gertz M. A. and Kyle R. A.: 1995 Hyperviscosity Syndrome. Journal of Intensive Care
Medicine 10 128-141.
