Association of nucleated red blood cell count with mortality among neonatal intensive care unit patients

Nucleated Red Blood Cells Are Predictive of In-Hospital Mortality for Pediatric Patients

PURPOSE

We sought to establish whether nucleated red blood cells (NRBCs) are predictive of disposition, morbidity, and mortality for pediatric patients presenting to the emergency department (ED).

METHODS

A single-center retrospective cohort study examining all ED encounters from patients aged younger than 19 years between January 2016 and March 2020, during which a complete blood count was obtained. Univariate analysis and multivariable logistic regression were used to test the presence of NRBCs as an independent predictor of patient-related outcomes.

RESULTS

The prevalence of NRBCs was 8.9% (4195/46,991 patient encounters). Patient with NRBCs were younger (median age 4.58 vs 8.23 years; P < 0.001). Those with NRBCs had higher rates of in-hospital mortality (30/2465 [1.22%] vs 65/21,741 [0.30%]; P < 0.001), sepsis (19% vs 12%; P < 0.001), shock (7% vs 4%; P < 0.001), and cardiopulmonary resuscitation (CPR) (0.62% vs 0.09%; P < 0.001). They were more likely to be admitted (59% vs 51%; P < 0.001), have longer median hospital length of stay {1.3 (interquartile range [IQR], 0.22-4.14) vs 0.8 days (IQR, 0.23-2.64); P < 0.001}, and median intensive care unit (ICU) length of stay (3.9 [IQR, 1.87-8.72] vs 2.6 days [IQR, 1.27-5.83]; P < 0.001). Multivariable regression revealed presence of NRBCs as an independent predictor for in-hospital mortality (adjusted odds ratio [aOR], 2.21; 95% confidence interval [CI], 1.38-3.53; P < 0.001), ICU admission (aOR, 1.30; 95% CI, 1.11-1.51; P < 0.001), CPR (aOR, 3.83; 95% CI, 2.33-6.30; P < 0.001), and 30-day return to the ED (aOR, 1.15; 95% CI, 1.15-1.26; P < 0.001).

CONCLUSIONS

The presence of NRBCs is an independent predictor for mortality, including in-hospital mortality, ICU admission, CPR, and readmission within 30 days for children presenting to the ED.

Diagnostic Value and Prognostic Significance of Nucleated Red Blood Cells (NRBCs) in Selected Medical Conditions

Nucleated red blood cells (NRBCs) are premature erythrocyte precursors that reside in the bone marrow of humans of all ages as an element of erythropoiesis. They rarely present in healthy adults' circulatory systems but can be found circulating in fetuses and neonates. An NRBC count is a cost-effective laboratory test that is currently rarely used in everyday clinical practice; it is mostly used in the diagnosis of hematological diseases/disorders relating to erythropoiesis, anemia, or hemolysis. However, according to several studies, it may be used as a biomarker in the diagnosis and clinical outcome prognosis of preterm infants or severely ill adult patients. This would allow for a quick diagnosis of life-threatening conditions and the prediction of a possible change in a patient's condition, especially in relation to patients in the intensive care unit. In this review, we sought to summarize the possible use of NRBCs as a prognostic marker in various disease entities. Research into the evaluation of the NRBCs in the pediatric population most often concerns neonatal hypoxia, the occurrence and consequences of asphyxia, and overall neonatal mortality. Among adults, NRBCs can be used to predict changes in clinical condition and mortality in critically ill patients, including those with sepsis, trauma, ARDS, acute pancreatitis, or severe cardiovascular disease.

Nucleated red blood cells explain most of the association between DNA methylation and gestational age

Determining if specific cell type(s) are responsible for an association between DNA methylation (DNAm) and a given phenotype is important for understanding the biological mechanisms underlying the association. Our EWAS of gestational age (GA) in 953 newborns from the Norwegian MoBa study identified 13,660 CpGs significantly associated with GA (p_Bonferroni<0.05) after adjustment for cell type composition. When the CellDMC algorithm was applied to explore cell-type specific effects, 2,330 CpGs were significantly associated with GA, mostly in nucleated red blood cells [nRBCs; n = 2,030 (87%)]. Similar patterns were found in another dataset based on a different array and when applying an alternative algorithm to CellDMC called Tensor Composition Analysis (TCA). Our findings point to nRBCs as the main cell type driving the DNAm-GA association, implicating an epigenetic signature of erythropoiesis as a likely mechanism. They also explain the poor correlation observed between epigenetic age clocks for newborns and those for adults.

Frequency of Nucleated Red Blood Cells in the Peripheral Blood of ICU-Admitted Patients

Background Nucleated red blood cells (NRBCs) are not normally found in the peripheral blood of normal healthy individuals. The presence of NRBCs on an adult peripheral blood smear indicates that there is an extremely high demand for the bone marrow to manufacture RBCs and that immature red blood cells are being released into the bloodstream. Anemia, myelofibrosis, thalassemia, miliary tuberculosis, malignancies of the bone marrow (myelomas, leukemias, lymphomas), and prolonged hypoxemia are a few possible pathogenic reasons. Critically ill patients who have NRBCs have a high mortality rate and a worse prognosis.

OBJECTIVE

To evaluate the clinical significance of NRBCs in the peripheral blood of critically ill patients admitted to the ICU to find a cut-off to predict mortality.

MATERIALS AND METHODS

A cross-sectional study was carried out over a period of six months September 1, 2020, to March 31, 2021, in Lahore, Pakistan. A total of 800 critically ill patients of both sexes in the age group of 18-70 years were included. Patients younger than 18 years and patients who underwent surgery were excluded. A quantity of 3 ml of whole blood sample in an ethylenediamine tetraacetic acid (EDTA) vial from each patient was run on SYSMEX XN-9000 (Sysmex Corporation, Kobe, Hyogo, Japan) and the results were reviewed on peripheral smears.

RESULTS

The incidence of NRBCs in ICU-admitted patients was 62.5% (500/800). The total number of NRBC-positive patients recovering after the treatment was 364 (72.8%). The overall mortality of NRBC-positive patients was 30% (150/500). It was significantly higher (p<0.001) than that of NRBC-negative patients (14%; 44/300). During treatment, the highest mortality rate was seen in patients due to malignancy (100%), followed by sepsis (58.8%). It was observed that the disease pattern and number of NRBCs were significantly different (p<0.001) among all disease groups. However, there was no statistically significant difference in NRBCs on the basis of gender (p >0.05). In our study, a cutoff of NRBCs of 2.50 showed a high risk of mortality with a sensitivity of 91%.

CONCLUSION

The presence of NRBCs may predict mortality in critically ill ICU-admitted patients. Their presence in the blood may be regarded as a marker of severity suggesting a high risk of ICU death.

Reference intervals of complete blood count parameters for individuals aged 80 to 89 years in Guizhou, China: A STROBE-compliant retrospective study

The reference intervals of complete blood count (CBC) parameters were commonly based on healthy individuals aged 20 to 79 years. However, these values are not optimal for correct clinical diagnosis in older individuals (e.g., 80-89 years). Although the reference intervals for this age group have been reported in China, there is no population-based report in Guizhou province. A total of 481 healthy adults (238 males and 243 females) aged 80 to 89 years were recruited from Affiliated Hospital of Zunyi Medical University in Guizhou. The CBC parameters were detected by Sysmex XN-9000 automatic hematology analyzer. The reference intervals of the components were analyzed according to the guidelines of International Federation of Clinical Chemistry. This study reported the reference intervals of CBC parameters. There were significant differences were examined in some reference intervals between the different gender groups, especially for RBC-related parameters. Compared with national standards, the most of all conventional reference intervals for CBC parameters were decreased. The present study provided the local reference intervals of CBC parameters for individuals aged 80 to 89 years in Guizhou, China. Some of our results were sex-specific, and most of our results show lower values while comparing with commonly used reference intervals in China. Therefore, more attentions should be paid to these differences, and accurate reference intervals will facilitate clinical diagnosis and decision-making in these populations.

Implications of an Elevated Nucleated Red Blood Cell Count in Neonates with Moderate to Severe Hypoxic-Ischemic Encephalopathy

OBJECTIVES

To investigate associations between nucleated red blood cell (NRBC) count in neonates with hypoxic-ischemic encephalopathy (HIE), acute perinatal sentinel events, and neurodevelopmental outcomes and to examine the mechanism(s) causing elevated counts.

STUDY DESIGN

We included newborn infants with HIE treated with therapeutic hypothermia with ≥3 NRBC counts during their neonatal intensive care unit hospitalization and neurodevelopmental evaluations at a mean of 24 ± 6 months.

RESULTS

Ninety-five of 152 infants who met our study criteria (63%) had a normal NRBC count after birth, defined as ≤95th percentile of the upper reference interval, and the other 57 (37%) had an elevated count. Documented sentinel events during labor resulting in emergency delivery (eg, acute abruption) (n = 79) were associated with a normal NRBC count (OR, 257; 95% CI, 33-1988). Of the 152 infants evaluated, 134 (88%) survived to discharge. The odds of surviving were 3-fold greater (OR, 3.0; 95% CI, 1.1-8.3) when the first NRBC count was normal than when it was elevated. Normal counts were moderately predictive of infants without neurodevelopmental impairment at a 2-year evaluation (P < .001). NRBC half-life was longer in infants with an elevated NRBC count compared with those with a normal count (60 hours vs 39 hours; P < .01).

CONCLUSIONS

In infants with HIE, a normal NRBC count after birth was associated with acute intrapartum events necessitating emergent delivery. Normal counts were modestly predictive of a better prognosis. We speculate that the elevated NRBC counts at birth resulted from hypoxia that occurred earlier or chronically. Impaired clearance of NRBCs from the blood might be one mechanistic explanation for the high counts.

The use of immature granulocyte and other complete blood count parameters in the diagnosis of transient tachypnea of the newborn

Background

Although Transient tachypnea of the newborn (TTN) is one of the most common causes of respiratory distress in the newborn period, there is no laboratory parameter used to diagnose it. Immatur granulocyte (IG) measurement is accepted as a useful indicator that can be used in early detection of many infectious conditions, especially neonatal sepsis. In this study, it was aimed to determine if IG and other complete blood count (CBC) parameters could be used as laboratory findings supporting TTN diagnosis.

Materials and methods

This study, which was retrospectively planned, was conducted in the neonatal intensive care unit (NICU) a public hospital between January 1, 2019 and January 31, 2021. Randomly selected 50 infants, hospitalized with the diagnosis of TTN, constituted the patient group of the study. 50 infants hospitalized with the diagnosis of hyperbilirubinemia and did not have any additional problems accepted as the control group. IG and other CBC parameters of infants in the patient and control groups were compared in the study.

Results

There was no significant difference between the patient and control groups in terms of demographic data and types of delivery (p > 0.05). The rate of delivery by elective cesarean section (C/S) was significantly higher than the rate of normal spontaneous vaginal (NSV) delivery in the patient group (p < 0.001). The IG number and percentage, WBC (white blood cell) count, RDW (red cell distribution width), number and percentage of NRBC (nucleated red blood cell), neutrophil and lymphocyte ratio, count and percentage of basophil and PLR (platelet/lymphocyte ratio) of the patient group was significantly higher than the control group (p < 0.05).

Conclusion

According to the findings obtained in the study, it was concluded that IG and other CBC parameters may be used to support clinical and imaging findings to diagnose transient tachypnea of the newborn.

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There was no significant difference between the patient and control groups in terms of demographic data and types of delivery.

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The rate of elective cesarean section (C/S) was significantly higher than normal spontaneous vaginal (NSV) delivery in the patient group.

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The IG number and percentage, WBC count, RDW, number and percentage of NRBC, neutrophil and lymphocyte ratio, count and percentage of basophil and PLR of the patient group was significantly higher than the control group.

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IG and other CBC parameters can be useful to support clinical and imaging findings to diagnose TTN.

Prognostic impacts of peripheral blood erythroblasts after single-unit cord blood transplantation

INTRODUCTION

The appearance of erythroblasts (EBLs) in peripheral blood occurs in a variety of serious conditions and has been associated with mortality in critically ill patients. However, the incidence, risk factor, and outcomes of EBLs after cord blood transplantation (CBT) remain unclear.

METHODS

We have investigated the impact of EBLs on transplant outcomes on 225 adult patients who underwent single-unit CBT at our single institute.

RESULTS

The cumulative incidences of EBL ≥200 × 10⁶ /L and EBL ≥1000 × 10⁶ /L at 60 days after CBT were 17% and 4%, respectively, detected after a median of 35 days and 36.5 days. Multivariate analysis using erythroblastosis as time-dependent covariates demonstrated the significant association of EBL ≥1000 × 10⁶ /L, but not EBL ≥200 × 10⁶ /L, with the development of grade III-IV acute graft-versus-host disease (GVHD, hazard ratio [HR]: 18.56; P < .001), higher nonrelapse mortality (HR: 13.38; P < .001), and overall mortality (HR: 4.97; P = .001).

CONCLUSION

These data suggested that higher levels of EBLs were recognized as a significant risk factor for severe acute GVHD and mortality after single-unit CBT. Higher levels of EBLs may serve as a surrogate marker for poor single CBT outcomes.

Nucleated Red Blood Cells: Could They Be Indicator Markers of Illness Severity for Neonatal Intensive Care Unit Patients?

Background: We aimed to assess whether nucleated red blood cells (NRBCs) count could serve as a diagnostic and prognostic biomarker for morbidity and mortality in critically ill neonates. Methods: The association between NRBCs count and neonatal morbidity and mortality was evaluated in an observational cohort of critically ill neonates hospitalized in our neonatal intensive care unit over a period of 69 months. The discriminative ability of NRBCs count as diagnostic and prognostic biomarkers was evaluated by performing the Receiver Operating Characteristics (ROC) curve analysis. Results: Among 467 critically ill neonates included in the study, 45 (9.6%) of them experienced in-hospital mortality. No statistically significant difference was found with regards to NRBCs count between survivors and non-survivors, although the median value for NRBCs was sometimes higher for non-survivors. ROC curve analysis showed that NRBCs is a good discriminator marker for the diagnosis of perinatal hypoxia in neonates with area under the curve (AUC) [AUC 0.710; 95% confidence interval (CI), 0.660–0.759] and predominantly in preterm neonates (AUC 0.921 (95% CI, 0.0849–0.0993)) by using a cut-off value of ≥11.2%, with 80% sensitivity and 88.7% specificity. NRBCs also revealed significant prognostic power for mortality in septic neonates (AUC 0.760 (95% CI, 0.631–0.888)) and especially in preterms with sepsis (AUC 0.816 (95% CI, 0.681–0.951)), with cut-off value ≥ 1%, resulting in 81.6% sensitivity and 78.1% specificity. Conclusion: NRBCs count may be included among the early diagnostic and prognostic markers for sick neonates.