Monocyte distribution width adds prognostic value in detection of COVID-19 respiratory failure

Monocyte distribution width as an early predictor of short-term outcome in adult patients with sepsis

OBJECTIVES

Monocyte distribution width (MDW) is a quantitative measurement of monocyte anisocytosis and has been proposed as an efficient marker for early sepsis detection. This study aimed to assess the prognostic potential of MDW in septic patients.

METHODS

In this study, a total of 252 adult septic patients were enrolled. Demographic, clinical, and laboratory finding including MDW and traditional inflammatory biomarkers detected at three time points (day 1, day 3 and day 6) after admission were collected and compared between 28-day survivors and non-survivors. Receiver operating characteristic (ROC) curves, Kaplan-Meier survival curve and Cox regression analyses were performed to assess and compare their predictive values. Group-based trajectory modeling was applied to identify MDW trajectory endotypes. Basic characteristics and 28-day outcomes were compared between the trajectories.

RESULTS

ROC curve analysis showed that MDW levels measured on day 3 after admission (D3-MDW) had moderate prognostic value and was independently associated with 28-day mortality in patients with sepsis. A D3-MDW value of 26.20 allowed discrimination between survivors and non-survivors with a sensitivity of 77.8 % and a specificity of 67.6 %. However, the prognostic accuracy of D3-MDW was diminished in immune-compromised patients and patients who already received antibiotics before admission. Group-based trajectory modeling indicated that excessively elevated and delayed decreased MDW levels during the first week after admission inversely correlated with prognosis.

CONCLUSIONS

MDW values detected on day 3 after admission and its kinetic change might be potential markers for predicting short-term outcome in adult septic patients.

Machine Learning Interpretability Methods to Characterize the Importance of Hematologic Biomarkers in Prognosticating Patients with Suspected Infection

Early detection of sepsis in patients admitted to the emergency department (ED) is an important clinical objective as early identification and treatment can help reduce morbidity and mortality rate of 20% or higher. Hematologic changes during sepsis-associated organ dysfunction are well established and a new biomarker called Monocyte Distribution Width (MDW) has been recently approved by the US Food and Drug Administration for sepsis. However, MDW, which quantifies monocyte activation in sepsis patients, is not a routinely reported parameter and it requires specialized proprietary laboratory equipment. Further, the relative importance of MDW as compared to other routinely available hematologic parameters and vital signs has not been studied, which makes it difficult for resource constrained hospital systems to make informed decisions in this regard. To address this issue, we analyzed data from a cohort of ED patients (n=10,229) admitted to a large regional safety-net hospital in Cleveland, Ohio with suspected infection who later developed poor outcomes associated with sepsis. We developed a new analytical framework consisting of seven data models and an ensemble of high accuracy machine learning (ML) algorithms (accuracy values ranging from 0.83 to 0.90) for the prediction of outcomes more common in sepsis than uncomplicated infection (3-day intensive care unit stay or death). To characterize the contributions of individual hematologic parameters, we applied the Local Interpretable Model-Agnostic Explanation (LIME) and Shapley Additive Value (SHAP) interpretability methods to the high accuracy ML algorithms. The ML interpretability results were consistent in their findings that the value of MDW is grossly attenuated in the presence of other routinely reported hematologic parameters and vital signs data. Further, this study for the first time shows that complete blood count with differential (CBC-DIFF) together with vital signs data can be used as a substitute for MDW in high accuracy ML algorithms to screen for poor outcomes associated with sepsis.

It's in the blood: a review of the hematological system in SARS-CoV-2-associated COVID-19

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented global healthcare crisis. While SARS-CoV-2-associated COVID-19 affects primarily the respiratory system, patients with COVID-19 frequently develop extrapulmonary manifestations. Notably, changes in the hematological system, including lymphocytopenia, neutrophilia and significant abnormalities of hemostatic markers, were observed early in the pandemic. Hematological manifestations have since been recognized as important parameters in the pathophysiology of SARS-CoV-2 and in the management of patients with COVID-19. In this narrative review, we summarize the state-of-the-art regarding the hematological and hemostatic abnormalities observed in patients with SARS-CoV-2-associated COVID-19, as well as the current understanding of the hematological system in the pathophysiology of acute and chronic SARS-CoV-2-associated COVID-19.

Monocyte Distribution Width Predicts Sepsis, Respiratory Failure, and Death in COVID-19

Introduction Sepsis is the leading cause of hospital mortality nationwide. Early recognition has been shown to improve outcomes. This research investigates the use of monocyte distribution width's (MDW) ability to detect sepsis and clinically correlate to outcomes in COVID-19 infection. Methods This is a retrospective, single-center cohort study of adult patients with confirmed COVID-19 requiring hospital admission over a 14-month period (September 2020 to November 2021). MDW was evaluated as a cytomarker to predict disease severity, mortality, and determination of sepsis in patients with COVID-19. Additionally, MDW was compared to existing inflammatory markers, including procalcitonin, D-dimer, ferritin, and lactic acid. Results MDW was able to predict sepsis in patients with COVID-19. The average MDW was found to be significantly higher in the detection of sepsis (25.50 ± 5.93) vs. patients without (23.13 ± 4.46) (p < 0.01). MDW was able to correlate with clinical outcomes or respiratory failure/hypoxia and death. An MDW value of 24.9 was shown to be the best cut-off value in determining fatal outcomes; receiver operating characteristic curve analysis revealed an area under the curve value of 0.69 (95% CI: 0.55-0.71) with a sensitivity of 83% and specificity of 71%. A chi-square test was performed, which detected a significant association between MDW values and the final clinical outcome of COVID-19 (OR = 3.52, 95% CI: 1.78-7.11, p < 0.001). Additionally, the mean MDW of patients with hypoxia or respiratory failure was significantly higher (22 vs. 25, p < 0.1). MDW did not correlate with any of the existing inflammatory markers. Conclusion MDW is a novel and reliable cytomarker for identifying sepsis in patients with COVID-19 infection. High MDW values are associated with clinical outcomes of respiratory failure and death with a mortality rate or absolute risk of 25%. MDW is easily obtained from routine laboratory evaluation in the emergency room and has the potential to be a useful tool in the triage of COVID-19 patients.

Monocyte distribution width alterations and cytokine storm are modulated by circulating histones

OBJECTIVES

Extracellular histone levels are associated with the severity of many human pathologies, including sepsis and COVID-19. This study aimed to investigate the role of extracellular histones on monocyte distribution width (MDW), and their effect on the release of cytokines by blood cells.

METHODS

Peripheral venous blood was collected from healthy subjects and treated with different doses of a histone mixture (range 0-200 μg/mL) to analyze MDW modifications up-to 3 h and digital microscopy of blood smears. Plasma obtained after 3 h of histone treatment were assayed to evaluate a panel of 24 inflammatory cytokines.

RESULTS

MDW values significantly increased in a time- and dose-dependent manner. These findings are associated with the histone-induced modifications of cell volume, cytoplasmic granularity, vacuolization, and nuclear structure of monocytes, promoting their heterogeneity without affecting their count. After 3 h of treatment almost all cytokines significantly increased in a dose-dependent manner. The most relevant response was shown by the significantly increased G-CSF levels, and by the increase of IL-1β, IL-6, MIP-1β, and IL-8 at the histone doses of 50, 100, and 200 µg/mL. VEGF, IP-10, GM-CSF, TNF-α, Eotaxin, and IL-2 were also up-regulated, and a lower but significant increase was observed for IL-15, IL-5, IL-17, bFGF, IL-10, IFN-γ, MCP-1, and IL-9.

CONCLUSIONS

Circulating histones critically induce functional alterations of monocytes mirrored by MDW, monocyte anisocytosis, and hyperinflammation/cytokine storm in sepsis and COVID-19. MDW and circulating histones may be useful tools to predict higher risks of worst outcomes.

Monocyte Distribution Width (MDW) in Patients with COVID-19: An Indicator of Disease Severity

Identifying patients with Coronavirus disease-2019 (COVID-19) who may have a severe illness is essential for timely intervention and decreasing the fatality rate. In the present study, we evaluated the performance of Monocyte Distribution Width (MDW) as a prognostic marker for identifying disease severity in COVID-19 patients. We included 145 patients with PCR-confirmed COVID-19 infection in the study. The performance of MDW was evaluated by calculating the area under the receiver operating characteristic curve (AUC), specificity, sensitivity, negative predictive value, and positive predictive value. Further analysis was conducted for the disease outcome, comparing COVID-19 patients discharged (n = 135) to deceased COVID-19 patients (n = 10). As a marker of disease severity, MDW demonstrated an AUC of 0.702 (95% CI 0.620-0.775) in ROC analysis. If MDW is considered a marker of patient outcome, AUC was 0.916 (95% CI 0.862-0.953), comparing deceased COVID-19 patients vs. those who survived. At a cut-off of > 25.4 on admission, MDW correlates well with poor disease outcomes in COVID-19 patients. MDW can be considered a helpful parameter in predicting the severity of COVID-19 disease and patient outcomes. Its role and incorporation in the standard diagnostic algorithm and management of COVID-19 patients need further validation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12288-023-01665-y.

Monocyte Distribution Width (MDW) as a biomarker of sepsis: An evidenced-based laboratory medicine approach

Monocyte Distribution Width (MDW) is a new generation cell blood count parameter providing a measure of monocyte anisocytosis. In the last decades, it has emerged as a reliable biomarker of sepsis in the acute setting, especially emergency department, and intensive care unit. MDW has several advantages over commonly used sepsis biomarkers, including low-cost, ease and speed of measurement. The clinical usefulness of MDW has been established in several studies and some clinical laboratory medicines have already implemented it in their routine. In this article, we describe the analytical and clinical features of MDW to guide its appropriate use in clinical practice by integrating the research evidence with real-world laboratory experience. The proper use of a biomarker is critical for improving patients' care and outcome as well as ensuring healthcare quality.

Deciphering the role of monocyte and monocyte distribution width (MDW) in COVID-19: an updated systematic review and meta-analysis

The SARS-CoV-2 infection is characterized by both systemic and organ hyper-thromboinflammation, with a clinical course ranging from mild up-to critical systemic dysfunction and death. In patients with coronavirus disease 2019 (COVID-19) the monocyte/macrophage population is deeply involved as both trigger and target, assuming the value of useful diagnostic/prognostic marker of innate cellular immunity. Several studies correlated morphological and immunophenotypic alterations of circulating monocytes with clinical outcomes in COVID-19 patients, concluding that monocyte distribution width (MDW) may retain clinical value in stratifying the risk of disease worsening. Through an electronic search in Medline and Scopus we performed an updated literature review and meta-analysis aimed to explore the association between increased MDW levels and illness severity in COVID-19 patients, deciphering role(s) and function(s) of monocytes in the harmful network underlining SARS-CoV-2 infection. We found that significantly elevated MDW values were frequently present in COVID-19 patients who developed unfavorable clinical outcomes, compounded by a significant association between monocyte anisocytosis and SARS-CoV-2 outcomes. These findings suggest that blood MDW index and its scatter plot could represent useful routine laboratory tools for early identification of patients at higher risk of unfavorable COVID-19 and for monitoring the progression of viral infection, clinical outcomes, and therapeutic efficacy throughout hospitalization. According to this evidence, therapeutic decisions in patients with SARS-CoV-2 infection could benefit from monitoring MDW value, with administration of drugs limiting thrombo-inflammation due to monocyte hyper-activation in patients with severe/critical COVID-19 disease.

Prognostic value of cellular population data in patients with COVID-19

Background and aims

Beckman Coulter hematology analysers identify leukocytes by their volume (V), conductivity (C) and scatter (S) of a laser beam at different angles. Each leukocyte sub-population [neutrophils (NE), lymphocytes (LY), monocytes (MO)] is characterized by the mean (MN) and the standard deviation (SD) of 7 measurements called "cellular population data" (@CPD), corresponding to morphological analysis of the leukocytes. As severe forms of infections to SARS-CoV-2 are characterized by a functional activation of mononuclear cells, leading to a cytokine storm, we evaluated whether CPD variations are correlated to the inflammation state, oxygen requirement and lung damage and whether CPD analysis could be useful for a triage of patients with COVID-19 in the Emergency Department (ED) and could help to identify patients with a high risk of worsening.

Materials and method

The CPD of 825 consecutive patients with proven COVID-19 presenting to the ED were recorded and compared to classical biochemical parameters, the need for hospitalization in the ward or ICU, the need for oxygen, or lung injury on CT-scan.

Results

40 of the 42 CPD were significantly modified in COVID-19 patients in comparison to 245 controls. @MN-V-MO and @SD-V-MO were highly correlated with C-reactive protein, procalcitonin, ferritin and D-dimers. SD-UMALS-LY > 21.45 and > 23.92 identified, respectively, patients with critical lung injuries (>75%) and requiring tracheal intubation. @SD-V-MO > 25.03 and @SD-V-NE > 19.4 identified patients required immediate ICU admission, whereas a @MN-V-MO < 183 suggested that the patient could be immediately discharged. Using logistic regression, the combination of 8 CPD with platelet and basophil counts and the existence of diabetes or obesity could identify patients requiring ICU after a first stay in conventional wards (area under the curve = 0.843).

Conclusion

CPD analysis constitutes an easy and inexpensive tool for triage and prognosis of COVID-19 patients in the ED.

Recent advances in laboratory hematology reflected by a decade of CCLM publications

On the occasion of the 60th anniversary of Clinical Chemistry and Laboratory Medicine (CCLM) we present a review of recent developments in the discipline of laboratory hematology as these are reflected by papers published in CCLM in the period 2012–2022. Since data on CCLM publications from 1963 to 2012 are also available, we were able to make a comparison between the two periods. This interestingly revealed that the share of laboratory hematology papers has steadily increased and reached now 16% of all papers published in CCLM. It also became evident that blood coagulation and fibrinolysis, erythrocytes, platelets and instrument and method evaluation constituted the ‘hottest’ topics with regard to number of publications. Some traditional, characteristic CCLM categories like reference intervals, standardization and harmonization, were more stable and probably will remain so in the future. With the advent of important newer topics, like new coagulation assays and drugs and cell population data generated by hematology analyzers, laboratory hematology is anticipated to remain a significant discipline in CCLM publications.