Red blood cell distribution width independently predicts 1-month mortality in acute decompensation of cirrhotic patients admitted to emergency department

Establishment and validation of a prognosis nomogram for MIMIC-III patients with liver cirrhosis complicated with hepatic encephalopathy

INTRODUCE

The purpose of this study was to establish a comprehensive prognosis nomogram for patients with liver cirrhosis complicated with hepatic encephalopathy (HE) in the intensive care unit (ICU) and to evaluate the predictive value of the nomogram.

METHOD

This study analyzed 620 patients with liver cirrhosis complicated with HE from the Medical Information Mart for Intensive Care III(MIMIC-III) database. The patients were randomly divided into two groups in a 7-to-3 ratio to form a training cohort (n = 434) and a validation cohort (n = 176). Cox regression analyses were used to identify associated risk variables. Based on the multivariate Cox regression model results, a nomogram was established using associated risk predictor variables to predict the 90-day survival rate of patients with cirrhosis complicated with HE. The new model was compared with the Sequential organ failure assessment (SOFA) scoring model in terms of the concordance index (C-index), the area under the curve (AUC) of receiver operating characteristic (ROC) analysis, the net reclassification improvement (NRI), the integrated discrimination improvement (IDI), calibration curve, and decision curve analysis (DCA).

RESULTS

This study showed that older age, higher mean heart rate, lower mean arterial pressure, lower mean temperature, higher SOFA score, higher RDW, and the use of albumin were risk factors for the prognosis of patients with liver cirrhosis complicated with HE. The use of proton pump inhibitors (PPI) was a protective factor. The performance of the nomogram was evaluated using the C-index, AUC, IDI value, NRI value, and DCA curve, showing that the nomogram was superior to that of the SOFA model alone. Calibration curve results showed that the nomogram had excellent calibration capability. The decision curve analysis confirmed the good clinical application ability of the nomogram.

CONCLUSION

This study is the first study of the 90-day survival rate prediction of cirrhotic patients with HE in ICU through the data of the MIMIC-III database. It is confirmed that the eight-factor nomogram has good efficiency in predicting the 90-day survival rate of patients.

Value of red blood cell distribution width in prediction of diastolic dysfunction in cirrhotic cardiomyopathy

BACKGROUND

Clinical diagnosis of cirrhotic cardiomyopathy (CCM) often encounters challenges of lack of timeliness and disease severity, with the commonly positive indicator usually associated with advanced heart failure.

AIM

To explore suitable biomarkers for early CCM prediction.

METHODS

A total of 505 eligible patients were enrolled in this study and divided into four groups according to Child-Pugh classification: Group I, Class A without CCM (105 cases); Group II, Class A with CCM (175 cases); Group III, Class B with CCM (139 cases); and Group IV, Class C with CCM (86 cases). Logistic regression and receiver operating characteristic (ROC) curve analyses were performed to determine whether red blood cell distribution width (RDW) was an independent risk factor for CCM risk. The relationships between RDW and Child-Pugh scores, Model for End-Stage Liver Disease (MELD) scores, and N-terminal pro-brain natriuretic peptide (NT-proBNP) were analyzed by Pearson correlation analysis.

RESULTS

A constant RDW increase was evident from Group I to Group IV (12.54 ± 0.85, 13.29 ± 1.19, 14.30 ± 1.96, and 16.25 ± 2.13, respectively). Pearson correlation analysis showed that RDW was positively correlated with Child-Pugh scores (r = 0.642, P < 0.001), MELD scores (r = 0.592, P < 0.001), and NT-proBNP (r = 0.715, P < 0.001). Furthermore, between Group I and Group II, RDW was the only significant index (odds ratio: 2.175, 95% confidence interval [CI]: 1.549-3.054, P < 0.001), and it reached statistical significance when examined by ROC curve analysis (area under the curve: 0.686, 95%CI: 0.624-0.748, P < 0.001).

CONCLUSION

RDW can serve as an effective and accessible clinical indicator for the prediction of diastolic dysfunction in CCM, in which a numerical value of more than 13.05% may indicate an increasing CCM risk.

Red cell distribution width and mortality in older patients with frailty in the emergency department

BACKGROUND

The red cell distribution width (RDW) reflects the degree of heterogeneity of red blood cells. Elevated RDW is associated both with frailty and with increased mortality in hospital-admitted patients. In this study we evaluate whether high RDW values are associated with mortality in older emergency department (ED) patients with frailty, and if the association is independent of the degree of frailty.

METHODS

We included ED patients with the following criteria: ≥ 75 years of age, Clinical Frailty Scale (CFS) score of 4 to 8, and RDW % measured within 48 h of ED admission. Patients were allocated to six classes by their RDW value: ≤ 13%, 14%, 15%, 16%, 17%, and ≥ 18%. The outcome was death within 30 days of ED admission. Crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) for a one-class increase in RDW for 30-day mortality were calculated via binary logistic regression analysis. Age, gender and CFS score were considered as potential confounders.

RESULTS

A total of 1407 patients (61.2% female), were included. The median age was 85 with an inter-quartile range (IQR) of 80-89, median CFS score 6 (IQR: 5-7), and median RDW 14 (IQR: 13-16). Of the included patients, 71.9% were admitted to hospital wards. A total of 85 patients (6.0%) died during the 30-day follow-up. Mortality rate was associated with RDW increase (p for trend < .001). Crude OR for a one-class increase in RDW for 30-day mortality was 1.32 (95% CI: 1.17-1.50, p < .001). When adjusted for age, gender and CFS-score, OR of mortality for one-class RDW increase was still 1.32 (95% CI: 1.16-1.50, p < .001).

CONCLUSION

Higher RDW values had a significant association with increased 30-day mortality risk in frail older adults in the ED, and this risk was independent of degree of frailty. RDW is a readily available biomarker for most ED patients. It might be beneficial to include it in risk stratification of older frail ED patients to identify those who could benefit from further diagnostic assessment, targeted interventions, and care planning.

Low Hemoglobin-to-Red Cell Distribution Width Ratio Is Associated with Mortality in Patients with HBV-Related Decompensated Cirrhosis

Background

The prognostic role of hemoglobin-to-red blood cell distribution width ratio (HRR) in HBV-related decompensated cirrhosis (HBV-DeCi) has not been established. The present study is aimed at determining the potential of HRR as a predictive factor for the prognosis of HBV-DeCi patients.

Methods

The study included 177 HBV-DeCi patients. The clinical outcome was death at 30 days. Multivariate regression analysis and receiver operating characteristic curve analysis were applied to assess the predictive value of HRR for poor outcomes.

Results

A total of 26 patients (14.7%) had died by 30 days. Patients with unfavorable outcomes had lower HRR than patients with favorable outcomes. Multivariate analysis revealed that HRR and Model for End-Stage Liver Disease (MELD) score were independently associated with poor outcomes. Combination of HRR and MELD score may improve prognostic accuracy in HBV-DeCi.

Conclusions

The present findings indicate that low HRR may be a promising predictor for mortality in HBV-DeCi patients.

Evaluation of prognostic value of neutrophil-to-lymphocyte ratio in patients with acute-on-chronic liver failure or severe liver injury from chronic HBV infection

BACKGROUND AND AIMS

Acute-on-chronic liver failure (ACLF) is associated with bacterial infection and poor outcome. Neutrophil-to-lymphocyte ratio (NLR) is used to assess bacterial infection and immune dysfunction in numerous diseases. We aimed to evaluate NLR as a prognostic biomarker and to explore its combination with accepted prognostic models in ACLF patients.

METHODS

This retrospective study included patients with ACLF or severe liver injury from chronic HBV infection admitted to three tertiary academic hospitals in China from 2013 to 2019. Baseline NLR was correlated with ACLF grade, bacterial infection, survival and accepted ACLF scores.

RESULTS

Baseline NLR values were significantly increased in nonsurvivors and patients with bacterial infection at or after admission and were unaffected by cirrhotic status in 412 transplant-free patients included in three cohorts. Compared with accepted scores, NLR showed moderate accuracy in predicting 28-day mortality and high accuracy in predicting 90-day mortality. Three levels of mortality risk were graded on the basis of NLR values (<3.10, 3.10-4.79 and >4.79), and NLR >4.79 was associated with 53.2-60.0% 28-day and 75.0-80.0% 90-day mortality in these cohorts. Multivariate analyses indicated that NLR retained statistical significance independently of CLIF consortium organ failure score (CLIF-C OFs). NLR-based CLIF-C ACLF score was primarily developed and showed excellent performance in predicting 28/90-day mortality.

CONCLUSIONS

NLR is a dependable biomarker for bacterial infection assessment and short-term mortality prediction in ACLF patients and can be used jointly with CLIF-C OFs to improve the accuracy of mortality prediction in patients with the disease. NLR-based CLIF-C ACLF model needs further validation.

Evaluating of Red Blood Cell Distribution Width, Comorbidities and Electrocardiographic Ratios as Predictors of Prognosis in Patients with Pulmonary Hypertension

Pulmonary hypertension is a rare condition that impairs patients' quality of life and life expectancy. The development of noninvasive instruments may help elucidate the prognosis of this cardiorespiratory disease. We aimed to evaluate the utility of routinely performed noninvasive test results as prognostic markers in patients with pulmonary hypertension. We enrolled 198 patients with mean pulmonary artery pressure >25 mmHg measured at cardiac catheterisation or echocardiographic pulmonary artery systolic pressure > 40 mmHg and tricuspid regurgitation Vmax >2.9 m/s, and clinical information regarding management and follow-up studies from the date of diagnosis. Multivariate analysis revealed that female sex [HR: 0.21, (95% CI: 0.07-0.64); p = 0.006], the presence of collagenopathies [HR: 8.63, (95% CI: 2.38-31.32); p = 0.001], an increased red blood cell distribution width [HR: 1.25, (95% CI: 1.04-1.49); p = 0.017] and an increased electrocardiographic P axis (P°)/T axis (T°) ratio [HR: 0.93, (95% CI: 0.88-0.98); p = 0.009] were severity-associated factors, while older age [HR: 1.57, (95% CI: 1.04-1.28); p = 0.006], an increased QRS axis (QRS°)/T° ratio [HR: 1.21, (95% CI: 1.09-1.34); p < 0.001], forced expiratory volume in 1 s [HR: 0.94, (95% CI: 0.91-0.98); p = 0.01] and haematocrit [HR: 0.93, (95% CI: 0.87-0.99); p = 0.04] were mortality-associated factors. Our results support the importance of red blood cell distribution width, electrocardiographic ratios and collagenopathies for assessing pulmonary hypertension prognosis.

Evaluation of the neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, and red cell distribution width for the prediction of prognosis of patients with hepatitis B virus-related decompensated cirrhosis

Background

The development and progression of hepatitis B virus‐related decompensated cirrhosis (DeCi) is associated with inflammatory responses. The monocyte‐to‐lymphocyte ratio (MLR), neutrophil‐to‐lymphocyte ratio (NLR), and red cell distribution width (RDW) are well‐known inflammation markers. We aimed to assess the utility of these parameters for predicating the prognosis of patients with HBV‐DeCi.

Methods

We retrospectively recruited 174 patients diagnosed with HBV‐DeCi. Univariate and multivariate regression models were used to determine risk factors for mortality. Areas under the receiver operating characteristic curves were calculated to estimate and compare the predictive values of the three parameters. Hepatic function was evaluated using the Model for End‐Stage Liver Disease (MELD) score.

Results

The NLR, RDW, and MLR were found to be significantly higher in patients who did not survive compared with surviving patients. Moreover, these variables were all able to predict early poor outcomes in patients with HBV‐DeCi, with NLR exhibiting the highest accuracy. Furthermore, a combination of the NLR and MELD score was a more accurate prognostic marker for predicting mortality than either marker alone in such patients.

Conclusions

Hematological parameters can provide prognostic information for patients with HBV‐DeCi. Routine assessment of these parameters at admission may provide valuable data to complement other conventional measures for assessing disease condition in patients with HBV‐DeCi.

Red blood cell distribution width: A promising index for evaluating the severity and long-term prognosis of hepatitis B virus-related diseases

BACKGROUND

We sought to explore the association of red blood cell distribution width (RDW) with the severity and long-term prognosis of chronic hepatitis B (CHB)-related liver diseases.

METHODS

1482 treatment-naïve CHB patients without liver cirrhosis (LC), 485 CHB-related LC (CHB-LC) patients and 325 healthy controls (HCs) were enrolled. The median follow-up time for CHB-LC patients was 33.9 months.

RESULTS

RDW was significantly higher in CHB-LC (15.0%) than CHB (12.7%) patients or HCs (12.5%). RDW was slightly higher in CHB patients than HCs (p < 0.001). Among CHB patients, the RDW of immune clearance and HBeAg negative hepatitis patients was significantly higher than immune-tolerant and low-replicative phase patients. RDW was positively correlated with Child-Turcotte-Pugh (r = 0.363; p < 0.001) and the model of end-stage liver disease scores (r = 0.218; p < 0.001). The areas under the receiver operating characteristic curve of RDW in predicting one-year, three-year, five-year and global mortality rates were 0.696, 0.668, 0.628 and 0.660, respectively. Through multivariable Cox regression analysis, RDW (p = 0.048) was identified as an independent predictor of liver-related mortality. Over a median follow-up of 33.9 months, CHB-LC patients with RDW ≥ 15.1% had significantly higher liver-related mortality than RDW < 15.1% patients (18.8% vs. 8.6%; p = 0.002).

CONCLUSIONS

RDW is positively associated with the severity of CHB and can independently predict the long-term prognosis of CHB-LC patients.

Fluid Biomarkers for Predicting the Prognosis of Liver Cirrhosis

Liver cirrhosis is the terminal stage of most chronic liver conditions, with a high risk of mortality. Careful evaluation of the prognosis of cirrhotic patients and providing precise management are crucial to reduce the risk of mortality. Although the liver biopsy and hepatic venous pressure gradient (HVPG) can efficiently evaluate the prognosis of cirrhotic patients, their application is limited due to the invasion procedures. Child-Pugh score and the model for end-stage liver disease (MELD) score had been widely used in the assessment of cirrhotic prognosis, but the defects of subjective variable application in Child-Pugh score and unsuitability to all phases of liver cirrhosis in MELD score limit their prognostic values. In recent years, continuous efforts have been made to investigate the prognostic value of body fluid biomarkers for cirrhotic patients, and promising results have been reported. Since the collection of fluid specimens is easy, noninvasive, and repeatable, fluid biomarkers can be ideal indicators to predict the prognosis of cirrhosis. Here, we reviewed noninvasive fluid biomarkers in different prognostic functions, including the prediction of survival and complication development.

[Red blood cell distribution width is a independent prognostic indicator for mortality in patients with HBV related acute-on-chronic liver failure]

OBJECTIVE

To establish a model for predicting the short-term prognosis of patients with HBV-related acute-onchronic liver failure (HBV-ACLF) based on red blood cell distribution width (RDW) and the model for end-stage liver disease (MELD) scores.

METHODS

A total of 245 patients with HBV-ACLF were retrospectively analyzed for their clinical data and results of routine hematological tests, liver function, renal function, coagulation test, HBV-DNA, and other indicators at admission. Univariate analysis and binary logistic regression analysis were used to test the short-term risk factors for death of the patients, and the MELD-RDW model was established. The accuracy of each index and the established model was verified using the ROC curve.

RESULTS

The surviving patients with HBV-ACLF had significantly decreased RDW (14.97 ± 1.38) and MELD score (23.54±4.35) compared with those in the patients dead within 90 days (17.05±2.92 and 28.95±5.99, respectively). Multivariate analysis indicated that RDW was a significant independent prognostic factor for mortality in patients with HBVACLF (OR=1.840, 95%CI: 1.47902.289, P &lt; 0.005). The risk assessment model was [logisticMELD-RDW]=-9.375+0.582×RDW- 0.091×ALB-0.05×PTA+0.186×MELD. The area under the ROC curve of MELD score combined with RDW was 0.878, which was higher than RDW (0.724) and MELD score (0.780) alone.

CONCLUSIONS

RDW is an independent prognostic indicator for mortality in patients with HBV-ACLF. Compared with MELD score, the risk assessment model based on MELD and RDW has a greater value in predicting the short-term prognosis of patients with HBV-ACLF.