Prognostic Value of Red Blood Cell Distribution Width in Non-Cardiovascular Critically or Acutely Patients: A Systematic Review

NLRP3 Contributes to Sarcopenia Associated to Dependency Recapitulating Inflammatory-Associated Muscle Degeneration

Sarcopenia, a complex and debilitating condition characterized by progressive deterioration of skeletal muscle, is the primary cause of age-associated disability and significantly impacts healthspan in elderly patients. Despite its prevalence among the aging population, the underlying molecular mechanisms are still under investigation. The NLRP3 inflammasome is crucial in the innate immune response and has a significant impact on diseases related to inflammation and aging. Here, we investigated the expression of the NLRP3 inflammasome pathway and pro-inflammatory cytokines in skeletal muscle and peripheral blood of dependent and independent patients who underwent hip surgery. Patients were categorized into independent and dependent individuals based on their Barthel Index. The expression of NLRP3 inflammasome components was significantly upregulated in sarcopenic muscle from dependent patients, accompanied by higher levels of Caspase-1, IL-1β and IL-6. Among older dependent individuals with sarcopenia, there was a significant increase in the MYH3/MYH2 ratio, indicating a transcriptional shift in expression from mature to developmental myosin isoforms. Creatine kinase levels and senescence markers were also higher in dependent patients, altogether resembling dystrophic diseases and indicating muscle degeneration. In summary, we present evidence for the involvement of the NLRP3/ASC/NEK7/Caspase-1 inflammasome pathway with activation of pro-inflammatory SASP in the outcome of sarcopenia in the elderly.

The association of hematological inflammatory markers and psychological function in COVID-19 patients: A cross-sectional study

Mental health disorders are linked to systemic inflammation. Due to high inflammation and mental health disorders in COVID-19 patients, we aimed to investigate the relationship between blood inflammatory markers such as red cell distribution width to platelet ratio (RPR), platelet-lymphocyte ratio (PLR), neutrophil/lymphocyte ratio (NLR), red cell distribution width (RDW), white blood cell (WBC), and psychological function in COVID-19 patients. In the current cross-sectional study, neuro-psychological function, and a complete blood count (CBC) were measured on 120 COVID-19 patients aged >30 years from the Imam Reza Hospital in Mashhad, Iran. Our results showed that anxiety related to MCHC (mean ± SD: 32.71 ± 1.68, p < 0.05), WBC (mean ± SD: 12.23 ± 5.43, p < 0.05), and PLR (median (IQR): 28.72 (15.88-41.31), p < 0.05) significantly. In the stress subgroup, only RPR was associated with stress (p < 0.05). Linear regression between hematological parameters and psychological score indicated that RDW and PLR had a significantly positive association with depression (β = 0.086; p = 0.045 and β = 1.326; p = 0.016, respectively) and anxiety scores (β = 0.100; p = 0.038 and β = 1.356; p = 0.010, respectively). Moreover, a positive correlation was found between PLR and stress (β = 1.102; p = 0.012). This study showed a positive association between depression/anxiety/stress symptoms and levels of hematological inflammatory markers including PLR and RDW. The findings of this study provide novel insights into mental health and physiological markers, underscoring the potential influence of inflammation on mood disorders. Our findings offer exciting prospects for future research and may lead to innovative approaches in the management and treatment of depression, anxiety, and stress.

The Emerging Clinical Significance of the Red Cell Distribution Width as a Biomarker in Chronic Obstructive Pulmonary Disease: A Systematic Review

There is an intense focus on the identification of novel biomarkers of chronic obstructive pulmonary disease (COPD) to enhance clinical decisions in patients with stable disease and acute exacerbations (AECOPD). Though several local (airway) and circulatory inflammatory biomarkers have been proposed, emerging evidence also suggests a potential role for routine haematological parameters, e.g., the red cell distribution width (RDW). We conducted a systematic literature search in PubMed, Web of Science, and Scopus, from inception to April 2022, for articles investigating the diagnostic and prognostic role of the RDW in stable COPD and AECOPD. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Significant associations between the RDW and the presence and severity of disease, outcomes (mortality, hospital readmission), and other relevant clinical parameters (right heart failure, pulmonary arterial hypertension) were reported in 13 out of 16 studies in stable COPD (low risk of bias in 11 studies), and 17 out of 21 studies of AECOPD (low risk of bias in 11 studies). Pending further research, our systematic review suggests that the RDW might be useful, singly or in combination with other parameters, for the diagnosis and risk stratification of patients with stable COPD and AECOPD (PROSPERO registration number: CRD42022348304).

Red Cell Distribution Width and Mortality in Patients Undergoing Percutaneous Coronary Intervention

Red cell distribution width (RDW) can effectively predict prognosis in coronary artery disease (CAD) patients following percutaneous coronary intervention (PCI). There is currently no relevant research to demonstrate a linear or non-linear association between RDW and mortality. This is a multi-center, retrospective cohort study, with data collected from 2006 to 2017. Source data included electronic medical records of the Integrated Medical Database of National Taiwan University Hospital, and health insurance claims from the National Health Insurance Administration. Patients were stratified into five groups according to RDW values (13.4%, 14.1%, 14.8%, and 15.9%). Multivariable logistic and Cox regression analyses were used to determine 1-year all-cause and cardiovascular (CV) mortalities. Data of 10,669 patients were analyzed and those with the lowest RDW (≤13.3%) served as the reference group. The adjusted odds ratios (ORs) of 1-year all-cause mortality from the second to fifth RDW group were 1.386, 1.589, 2.090, and 3.192, respectively (p for trend < 0.001). The adjusted ORs of 1-year CV mortality were 1.555, 1.585, 1.623, and 2.850, respectively (p for trend = 0.015). The adjusted hazard ratios (HRs) of 1-year all-cause mortality were 1.394, 1.592, 2.003, and 2.689, respectively (p for trend = 0.006). The adjusted HRs of 1-year CV mortality were 1.533, 1.568, 1.609, and 2.710, respectively (p for trend = 0.015). RDW was an independent predicting factor and had a linear relationship with the 1-year all-cause and CV mortalities in patients undergoing PCI. Thus, RDW may be a clinically useful parameter to predict the mortality in those patients.

Microfluidic Characterization of Red Blood Cells Microcirculation under Oxidative Stress

Microcirculation is one of the basic functional processes where the main gas exchange between red blood cells (RBCs) and surrounding tissues occurs. It is greatly influenced by the shape and deformability of RBCs, which can be affected by oxidative stress induced by different drugs and diseases leading to anemia. Here we investigated how in vitro microfluidic characterization of RBCs transit velocity in microcapillaries can indicate cells damage and its correlation with clinical hematological analysis. For this purpose, we compared an SU-8 mold with an Si-etched mold for fabrication of PDMS microfluidic devices and quantitatively figured out that oxidative stress induced by tert-Butyl hydroperoxide splits all RBCs into two subpopulations of normal and slow cells according to their transit velocity. Obtained results agree with the hematological analysis showing that such changes in RBCs velocities are due to violations of shape, volume, and increased heterogeneity of the cells. These data show that characterization of RBCs transport in microfluidic devices can directly reveal violations of microcirculation caused by oxidative stress. Therefore, it can be used for characterization of the ability of RBCs to move in microcapillaries, estimating possible side effects of cancer chemotherapy, and predicting the risk of anemia.

The Association between Peripheral Blood Cells and the Frailty Syndrome in Patients with Cardiovascular Diseases

Background

Frailty syndrome is characterized by multisystem dysregulation frequently found in older individuals or even in younger patients with chronic disabling diseases such as cardiovascular diseases.

Objective

To determine whether peripheral blood cell count, and its subpopulations, red blood cell and platelets, morphology and different ratios (neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and red blood distribution width-to-platelet ratio) are associated with cardiac frail patients, and through this to improve the prediction of frailty status in patients with cardiovascular diseases.

Methods

An observational, retrospective, cohort study enrolling 179 patients with cardiovascular disease divided into two groups: non-frail group (100 pts) and frail group (79 pts), a cohort detached from the Frail.RO study. The frailty was evaluated based on the Fried criteria; haematological markers, sociodemographic data, and variables related to cardiovascular diseases and comorbidities were also recorded.

Results

Lower lymphocytes, platelet count, and neutrophil-to-lymphocyte ratio were significantly associated with a more severe frailty syndrome. Regarding red blood cells, haemoglobin concentration and red cell distribution width significantly correlated with the severity of the frailty syndrome. Receiver operating characteristic curve analysis for these markers associated with the frailty syndrome revealed an acceptable sensitivity of 66% and specificity of 65% to identify frail individuals. Malnutrition and hypercholesterolemia are relevant predictors for identifying frailty in hospitalized cardiovascular patients.

Conclusion

The evaluation of peripheral blood cell composition routinely measured in clinical practice can represent a valuable, but limited indicator, to diagnose frailty syndrome and eventually, the effects of interventions in frail patients with cardiovascular diseases.

Biomarkers of Inflammation and Inflammation-Related Indexes upon Emergency Department Admission Are Predictive for the Risk of Intensive Care Unit Hospitalization and Mortality in Acute Poisoning: A 6-Year Prospective Observational Study

Patients poisoned with drugs and nonpharmaceutical substances are frequently admitted from the emergency department (ED) to a medical or ICU department. We hypothesized that biomarkers of inflammation and inflammation-related indexes based on the complete blood cell (CBC) count can identify acutely poisoned patients at increased risk for ICU hospitalization and death. We performed a 6-year prospective cohort study on 1548 adult patients. The demographic data, the levels of hs-CRP (high-sensitivity C-reactive protein), CBC, and inflammation-related indexes based on CBC counts were collected upon admission and compared between survivors and nonsurvivors, based on the poison involved. Both a multivariate logistic regression model with only significant univariate predictors and a model including univariate predictors plus each log-transformed inflammation-related indexes for mortality were constructed. The importance of the variables for mortality was graphically represented using the nomogram. hs-CRP (odds ratio (OR), 1.38; 95% CI, 1.16–1.65, p < 0.001 for log-transformed hs-CRP), red cell distribution width (RDW), neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) were significantly associated with the risk of ICU hospitalization, after multivariable adjustment. Only RDW, NLR, and monocyte-lymphocyte ratio (MLR) were significantly associated with mortality. The predictive accuracy for mortality of the models which included either NLR (AUC 0.917, 95% CI 0.886-0.948) or MLR (AUC 0.916, 95% CI 0.884-0.948) showed a high ability for prognostic detection. The use of hs-CRP, RDW, NLR, and MLR upon ED admission are promising screening tools for predicting the outcomes of patients acutely intoxicated with undifferentiated poisons.

Serological Biomarkers and Indices for the Current Activity and Prognosis of ANCA-Associated Vasculitis: Experience in a Single Centre in Korea

Small vessel vasculitis is composed of two types of vasculitis based on immune-complex deposits, immune-complex vasculitis and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) according to the 2012 Chapel Hill Consensus Conferences Nomenclature of Vasculitis. In general, the current disease-states are assessed in three ways in real clinical practice such as activity, damage and functional status. Birmingham vasculitis activity score (BVAS, version 3) and five-factor score were calculated for assessing the cross-sectional activity and for predicting the prognosis of AAV, respectively. Since BVAS includes a wide spectrum of nine systemic items with differently weighted scores based on new-onset/worsening or persistent each symptom, it has been considered as the most reliable tool to assess AAV activity to date. However, since BVAS represents both cross-sectional and chronic clinical features, it has a limitation in flexibly reflecting the cross-sectional activity or severity of AAV. In addition, the heterogeneous items of BVAS are difficult to reflect the close correlation between BVAS and AAV pathogenesis. It is practically difficult to discover new biomarkers or indices that exceed the reliability of AAV-specific indices or acute-phase reactants established by long clinical experience. However, efforts to discover and develop new biomarkers or indices are expected to complement the clinical unmet need of existing AAV-specific indices and acute-phase reactants. In this review, we reviewed the serological biomarkers and indices that have been reported to date and introduced studies that investigated serological biomarkers and indices in Korean patients with AAV.

Red Blood Cell Distribution Width, Disease Severity, and Mortality in Hospitalized Patients with SARS-CoV-2 Infection: A Systematic Review and Meta-Analysis

The identification of biomarkers predicting disease severity and outcomes is the focus of intense research in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 infection). Ideally, such biomarkers should be easily derivable from routine tests. We conducted a systematic review and meta-analysis of the predictive role of the red blood cell distribution width (RDW), a routine hematological test, in patients with SARS-CoV-2 infection. We searched the electronic databases PubMed, Web of Science and Scopus, from January 2020 to November 2020, for studies reporting data on the RDW and coronavirus disease 2019 (COVID-19) severity, defined as severe illness or admission to the intensive care unit (ICU), and mortality. Eleven studies in 4901 COVID-19 patients were selected for the meta-analysis. Pooled results showed that the RDW values were significantly higher in patients with severe disease and non-survivors (standard mean difference, SMD = 0.56, 95% CI 0.31 to 0.81, p < 0.001). Heterogeneity between studies was extreme (I² = 80.6%; p < 0.001). In sensitivity analysis, the effect size was not modified when each study was in turn removed (effect size range, between 0.47 and 0.63). The Begg’s (p = 0.53) and Egger’s tests (p = 0.52) showed no evidence of publication bias. No significant correlations were observed between SMD and age, gender, whole blood count, end point, study geographic area, or design. Our meta-analysis showed that higher RDW values are significantly associated with COVID-19 severity and mortality. This routine parameter might assist with early risk stratification in patients with SARS-CoV-2 infection.

Initial red cell distribution width as a predictor of poor neurological outcomes in out-of-hospital cardiac arrest survivors in a prospective, multicenter observational study (the KoCARC study)

This study aimed to investigate whether the initial red cell distribution width (RDW) at the emergency department (ED) is associated with poor neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors. We performed a prospective observational analysis of patients admitted to the ED between October 2015 and June 2018 from the Korean Cardiac Arrest Research Consortium registry. We included OHCA patients who visited the ED and achieved return of spontaneous circulation. Initial RDW values were measured at the time of the ED visit. The primary outcome was a poor neurological (Cerebral Performance Category, or CPC) score of 3–5. A total of 1008 patients were ultimately included in this study, of whom 712 (70.6%) had poor CPC scores with unfavorable outcomes. Higher RDW quartiles (RDW 13.6–14.9%, RDW ≥ 15.0%), older age, female sex, nonshockable initial rhythm at the scene, unwitnessed cardiac arrest, bystander cardiopulmonary resuscitation (CPR), medical history, low white blood cell counts and high glucose levels were associated with poor neurological outcomes in univariate analysis. In multivariate analysis, the highest RDW quartile was independently associated with poor neurological outcomes (odds ratio 2.04; 95% confidence interval 1.12–3.69; p = 0.019) at hospital discharge after adjusting for other confounding factors. Other independent factors including age, initial rhythm, bystander CPR and high glucose were also associated with poor neurological outcomes. These results show that an initial RDW in the highest quartile as of the ED visit is associated with poor neurological outcomes at hospital discharge among OHCA survivors.

Anisocytosis is Associated With Short-Term Mortality in COVID-19 and May Reflect Proinflammatory Signature in Uninfected Ambulatory Adults

BACKGROUND

Red cell distribution width (RDW), a measure of anisocytosis, is observed in chronic inflammation and is a prognostic marker in critically ill patients without COVID-19, but data in COVID-19 are limited.

METHODS

Between March 12 and April 19, 2020, 282 individuals with confirmed COVID-19 and RDW available within 7 days prior to COVID-19 confirmation were evaluated. Individuals were grouped by quartiles of RDW. Association between quartiles of RDW and mortality was assessed using the Kaplan-Meier method and statistical significance was assessed using the log-rank test. The association between RDW and all-cause mortality was further assessed using a Cox proportional hazards model. Plasma cytokine levels in uninfected ambulatory adults without cardiovascular disease (n=38) were measured and bivariate Spearman correlations and principle components analysis were used to identify relationships between cytokine concentrations with RDW.

RESULTS

After adjusting for age, sex, race, cardiovascular disease, and hemoglobin, there was an association between RDW and mortality (Quartile 4 vs Quartile 1: HR 4.04 [1.08-15.07]), with each 1% increment in RDW associated with a 39% increased rate of mortality (HR 1.39 [1.21-1.59]). Remote RDW was also associated with mortality after COVID-19 infection. Among uninfected ambulatory adults without cardiovascular disease, RDW was associated with elevated pro-inflammatory cytokines (TNF-α, IL8, IL6, IL1b), but not regulatory cytokines (TGFb).

CONCLUSIONS

Anisocytosis predicts short-term mortality in COVID-19 patients, often predates viral exposure, and may be related to a pro-inflammatory phenotype. Additional study of whether the RDW can assist in the early identification of pending cytokine storm is warranted.

Red Blood Cell Distribution Width (RDW) Predicts COVID-19 Severity: A Prospective, Observational Study from the Cincinnati SARS-CoV-2 Emergency Department Cohort

Since previous evidence has demonstrated that red blood cell distribution width (RDW) may be a useful prognostic parameter in many critical illnesses and infectious diseases, we investigated the utility of RDW for monitoring patients with coronavirus disease 2019 (COVID-19). The study population consisted of 49 COVID-19 patients, including 16 (32.6%) with severe illness, 12 (24.5%) with severe acute kidney injury (AKI), and 8 (16.3%) requiring renal replacement therapy (RRT). The predictive value of blood tests, performed during emergency department evaluation, was then addressed. A progressive increase of RDW was observed with advancing COVID-19 severity. The area under the curve (AUC) of RDW was 0.73 for predicting severe illness, 0.80 for severe AKI, and 0.83 for RRT, respectively. In multivariate analysis, elevated RDW was associated with 9-fold and 16-fold increased odds of severe COVID-19 and AKI, respectively. The results of this study suggest that RDW should be part of routine laboratory assessment and monitoring of COVID-19.

Trends of utilization of Complete Blood Count parameters for patient management among doctors in Azad Kashmir

Objective:

To determine the trends of utilization of CBC parameters in patient management among doctors in different hospitals in Kashmir, Pakistan.

Methodd:

A self-administered questionnaire-based survey was carried out amongst doctors working in four hospitals of Kashmir i.e. Combined Military Hospital, Muzaffarabad, Combined Military Hospital, Rawalakot, Abbas Institute of Medical Sciences, Muzaffarabad, and District Hospital, Kotli during August to December 2017.

Results:

Out of 500 physicians, 217 physicians answered the questionnaire, representing a response rate of 43.4%. Only three of the 11 parameters in the CBC report i.e. hemoglobin, white blood cell count and platelets were selected as frequently or always useful by more than 80% of physicians. Rest of the eight parameters of the CBC were found useful by less than 80% of the physicians. Most agreed that the current format of a CBC report gives adequate information.

Conclusion:

The present study concludes that majority of the physicians utilize only three of the basic parameters on the complete blood count. An educational intervention can be planned for the physicians to increase their knowledge about the utility of other parameters.

Association between anemia and hematological indices with mortality among cardiac intensive care unit patients

Background

Anemia and elevated red cell distribution width (RDW) or mean corpuscular volume (MCV) are associated with an adverse prognosis in patients with cardiovascular disease and critical illness. Limited data exist regarding these associations in unselected cardiac intensive care unit (CICU) patients.

Methods

Retrospective cohort study of CICU patients between January 1, 2007, and December 31, 2015, with a hemoglobin (Hb) level measured at admission. Multivariable regression was performed to determine predictors of hospital mortality, and Kaplan–Meier analysis was used to determine post-discharge survival.

Results

We included 9644 patients with a mean age of 67.5 ± 15.1 years, including 3604 (37.4%) females. The median (IQR) values of Hb, MCV and RDW were 12.2 g/dL (10.6, 13.7), 90.7 fL (87.3, 94.2) fL, and 14.1% (13.3, 15.8), respectively. Anemia (admission Hb < 12 g/dL) was present in 4434 (46%) patients. A total of 845 (8.8%) patients died in the hospital. Patients with anemia had higher hospital mortality (11.3% vs. 6.6%, unadjusted OR 1.82, 95% CI 1.58–2.10, p < 0.001). After multivariable regression, admission Hb and MCV were not significantly associated with hospital mortality (both p > 0.1), while admission RDW (adjusted OR 1.12 per 1%, 95% CI 1.07–1.18, p < 0.001) was significantly associated with hospital mortality. Hospital survivors with lower Hb, higher MCV, or higher RDW had lower post-discharge survival.

Conclusion

Elevated RDW on admission was independently associated with higher hospital mortality in CICU patients. These data emphasize the importance of hematologic abnormalities for mortality risk stratification in CICU populations.

Graphic abstract

Electronic supplementary material

The online version of this article (10.1007/s00392-019-01549-0) contains supplementary material, which is available to authorized users.

Derivation and Validation of a Novel Cardiac Intensive Care Unit Admission Risk Score for Mortality

Background

There are no risk scores designed specifically for mortality risk prediction in unselected cardiac intensive care unit (CICU) patients. We sought to develop a novel CICU‐specific risk score for prediction of hospital mortality using variables available at the time of CICU admission.

Methods and Results

A database of CICU patients admitted from January 1, 2007 to April 30, 2018 was divided into derivation and validation cohorts. The top 7 predictors of hospital mortality were identified using stepwise backward regression, then used to develop the Mayo CICU Admission Risk Score (M‐CARS), with integer scores ranging from 0 to 10. Discrimination was assessed using area under the receiver‐operator curve analysis. Calibration was assessed using the Hosmer–Lemeshow statistic. The derivation cohort included 10 004 patients and the validation cohort included 2634 patients (mean age 67.6 years, 37.7% females). Hospital mortality was 9.2%. Predictor variables included in the M‐CARS were cardiac arrest, shock, respiratory failure, Braden skin score, blood urea nitrogen, anion gap and red blood cell distribution width at the time of CICU admission. The M‐CARS showed a graded relationship with hospital mortality (odds ratio 1.84 for each 1‐point increase in M‐CARS, 95% CI 1.78–1.89). In the validation cohort, the M‐CARS had an area under the receiver‐operator curve of 0.86 for hospital mortality, with good calibration (P=0.21). The 47.1% of patients with M‐CARS <2 had hospital mortality of 0.8%, and the 5.2% of patients with M‐CARS >6 had hospital mortality of 51.6%.

Conclusions

Using 7 variables available at the time of CICU admission, the M‐CARS can predict hospital mortality in unselected CICU patients with excellent discrimination.

Prognostic significance of red cell distribution width in hospitalized older patients with heart failure or infection

AIM

Red cell distribution width (RDW) is a simple, sensitive and cost-effective parameter, and is associated with pathophysiology of many common diseases. The aim of the present study was to investigate the prognostic role of RDW in older adults hospitalized for the treatment of heart failure (HF) or infection, because both diseases are fatal, especially in the geriatric population.

METHODS

This observational study consecutively enrolled 196 Japanese older (aged ≥75 years) patients hospitalized for the treatment of HF (group A, n = 102) or non-cardiovascular bacterial infection (group B, n = 94). Baseline and clinical data were extracted from medical records. The observational period was that of hospitalization. The primary end-point was classified in the order of discharge to the patients' home, discharge to other facilities and in-hospital death.

RESULTS

Longer hospital stay (P < 0.01) and worse prognosis (P < 0.01), including higher in-hospital mortality, were found in patients showing RDW ≥15% relative to those with RDW <15% in both groups. RDW showed no in-hospital variation despite successful treatment of acutely decompensated HF in selected patients of group A (n = 64).

CONCLUSIONS

The present study showed the role of RDW in predicting the prognostic outcome of older adults hospitalized for the treatment of HF or infection, indicating that RDW is a stable and reliable parameter in these common diseases. Geriatr Gerontol Int 2019; 19: 988-992.

Incidence and significance of an elevated red blood cell distribution width among hospitalised HIV-infected adult patients

We audited the records of unselected hospitalised HIV-positive adults admitted to a University-affiliated inner London hospital to identify the frequency of elevated red blood cell distribution width (RDW), and potential associations with specific diagnoses, and with outcome. Of 259 patients audited, 188 (73%) were men. Patients’ median age was 47 years (interquartile range = 41–54). An elevated RDW was seen in 50 patients (19%); 200 (77%) had an elevated C-reactive protein (CRP), and 77 (30%) had a low haemoglobin. Only five patients had an elevated RDW without an elevated CRP and/or low haemoglobin. An elevated RDW was associated with a wide range of infectious, inflammatory, and malignant conditions similar to observed associations reported in the general non-HIV infected adult population. Additionally an elevated RDW occurred both in patients with well-controlled HIV infection and in receipt of antiretroviral therapy, as well as in those with newly diagnosed and poorly-controlled infection. Five (10%) of 50 patients with an elevated RDW needed intensive care unit (ICU) admission and two (4%) died. Two (0.95%) of 209 patients with a normal RDW needed ICU admission and four (1.9%) died. The findings of this audit are limited by the relatively small number of patients and the single site nature of the audit.

Usefulness of RBC distribution width and C-reactive protein to predict mortality in pediatric non-cardiac critical illness

INTRODUCTION

We aimed to assess the performance of red blood cell distribution width (RDW), C-reactive protein (CRP) or the combination of both to predict clinical outcomes in pediatric non-cardiovascular critical illness.

MATERIALS AND METHODS

We analyzed 404 pediatric non-cardiovascular critically ill patients admitted to pediatric intensive care unit (PICU). Potential predictors were identified using multivariable logistic regression. We also calculated the power of RDW and CRP additive to pediatric critical illness score (PCIS) to predict mortality with calculation of C-index value, integrated discrimination improvement (IDI) and net reclassification improvement (NRI) indices.

RESULTS

RDW and CRP independently predicted PICU mortality. The C-index value of PCIS with respect to prediction of PICU mortality was greater than that of RDW and CRP. The combination of RDW or CRP or both with PCIS did significantly increase C-index value for predicting mortality (all p < 0.01). Addition of RDW or CRP or their combination to PCIS provided IDI of 7%, 1.1% and 9.4% (p = 0.009, 0.01 and 0.003) and NRI of 15.9%, 13.1% and 19.6% (p = 0.002, 0.043 and 0.002), respectively.

CONCLUSIONS

In pediatric non-cardiovascular critically ill patients, RDW and CRP could serve as independent predictors of PICU mortality and addition of RDW or CRP or both to PCIS significantly improves the ability to predict PICU mortality.

Diagnostic and Prognostic Relevance of Red Blood Cell Distribution Width for Vascular Aging and Cardiovascular Diseases

Evidence suggests association of red blood cell distribution width (RDW) with cardiovascular diseases (CVDs). On the contrary, we underline that the sole RDW values cannot represent a valid CVD biomarker. High RDW values are expression of biological effects of a lot of both endogenous and exogenous factors (i.e., age, sex, genetic background, inflammation, hormones, drugs, diet, exercise, hematological analyzers, and ranges of values), modulating the biology and physiology of erythrocytes. Thus, the singular monitoring of RDW cannot be used to predict cardiovascular disorders. Accordingly, we have reviewed the evidence for potential relationship of RDW values with alterations in the cardiovascular system (i.e., regenerative capacity, endothelial turnover, and senescence of cardiovascular cells), associated with vascular aging and disease. In addition, we highlight the inevitable impact of biases in clinical application of RDW related to CVDs. Based on our thorough review of literature, we suggest a combined evaluation of RDW with other emerging biomarkers related to vascular aging and the diagnosis and prognosis of CVDs, including telomere length of leukocytes, circulating nucleated red blood cells (nRBCs) and endothelial progenitor cells (EPCs) in future large scale studies.

The Association between Red Blood Cell Distribution Width and Sarcopenia in U.S. Adults

One pathophysiological sign of sarcopenia is chronic inflammation. Given that levels of red blood cell distribution width (RDW) are increased in chronic inflammation, we evaluated the association between increased RDW and sarcopenia among adults in the general U. S. population and analyzed data from 11,761 participants from the National Health and Nutrition Examination Survey (NHANES) 1999–2006. Sarcopenia was defined as an appendicular skeletal muscle mass (ASM) divided by weight (%) that was less than one standard deviation (SD) below the mean of young adults. The odds ratios (ORs) and confidence intervals (CIs) for sarcopenia were calculated across RDW quartiles after adjusting for confounding factors. Elevated RDW levels were significantly associated with sarcopenia after adjusting for age, sex, race, education, household income, smoking, physical activity, hypertension, diabetes, cardiovascular disease, C-reactive protein, and hemoglobin (OR of highest quartile: 1.72 (95% CI: 1.43, 2.06)). Further, in a model stratified by obesity, an elevated RDW was associated with sarcopenia in the overweight and obese group, but not in the normal weight group. Our study shows that elevated RDW is associated with sarcopenia, and this association is particularly strong in people who are overweight and obese.

Value of neutrophil to lymphocyte ratio combined with red blood cell distribution width for predicting severity of acute pancreatitis

AIM

To explore the value of neutrophil to lymphocyte ratio (NLR) combined with red blood cell distribution width (RDW) for predicting the severity of acute pancreatitis (AP).

METHODS

The clinical data of 120 patients with AP were retrospectively analyzed in this study. The patients were assigned to three groups: mild AP (MAP) group, moderately severe AP (MSAP) group, and severe AP (SAP) group. The clinical indexes (NLR and RDW) of the three groups of patients were measured at 24 h after hospitalization. All of these data were compared among the groups, and between dead patients and surviving cases. The receiver operator characteristic curves (ROCs) of NLR, RDW, and NLR plus RDW were plotted to assess their value in predicting the prognosis of AP.

RESULTS

With the increase of the severity of AP, the value of NLR increased significantly (P < 0.05). There was no significant difference in RDW between the MAP and MSAP groups (P > 0.05). The RDW value of the SAP group was significantly different from those of the MAP and MSAP groups (P < 0.05). The values of NLR and RDW in the death group were significantly higher than those in the survival group (P < 0.05). The area under the curve of NLR in predicting AP severity was 0.794, which was significantly higher than that of RDW (0.745; P < 0.05). The area under the NLR + RDW curve was 0.876 (sensitivity, 0.795; specificity, 0.852), which was significantly higher than that of NLR and RDW alone (P < 0.05).

CONCLUSION

NLR and RDW are both related to the severity of AP, and the combination of the two indexes can improve the sensitivity and specificity of predicting the severity of AP.

Red cell distribution width and renal outcome in patients with non-dialysis-dependent chronic kidney disease

Higher red cell distribution width (RDW) has been reported to predict mortality among patients with various diseases, including chronic kidney disease (CKD). However, whether RDW is associated with renal outcome remains unclear. We investigated the relationship between RDW and renal outcome in patients with non-dialysis-dependent CKD (NDD-CKD). This prospective, observational study of patients with CKD was conducted at a single nephrology department. First, we performed regression analyses for the decline in estimated glomerular filtration rate (eGFR) during the first 3 months of observation to determine its short-term association with RDW. Next, we categorized baseline RDW into two groups by its median (13.5%) and performed Cox regression analyses to investigate whether higher RDW was an independent predictor of renal outcomes defined as a composite of the initiation of dialysis and doubling of the serum creatinine concentration. Furthermore, we repeated the analyses to confirm whether the transition of the RDW category during the first 3 months would also predict renal outcomes. We enrolled 703 patients. Baseline RDW showed a non-linear association with the eGFR decline during the first 3 months, with a greater negative correlation at the lower end of the RDW distribution. Over a median follow-up of 1.8 years, 178 patients (25.3%) reached the renal endpoint. Multivariable Cox regression analyses showed that patients with higher RDW had a higher risk of developing renal outcomes (adjusted hazard ratio [HR]: 1.47, 95% confidence interval [CI]: 1.05–2.07) than did those with lower RDW. Furthermore, patients with sustained, higher RDW demonstrated a significantly higher risk than did those with consistently lower RDW (adjusted HR: 1.65, 95% CI: 1.02–2.67). In conclusion, higher RDW was independently associated with worse renal outcome in patients with NDD-CKD. RDW could be an additional prognostic marker of the progression of CKD.

Preoperative Red Cell Distribution Width and 30-day mortality in older patients undergoing non-cardiac surgery: a retrospective cohort observational study

Increased red cell distribution width (RDW) is associated with poorer outcomes in various patient populations. We investigated the association between preoperative RDW and anaemia on 30-day postoperative mortality among elderly patients undergoing non-cardiac surgery. Medical records of 24,579 patients aged 65 and older who underwent surgery under anaesthesia between 1 January 2012 and 31 October 2016 were retrospectively analysed. Patients who died within 30 days had higher median RDW (15.0%) than those who were alive (13.4%). Based on multivariate logistic regression, in our cohort of elderly patients undergoing non-cardiac surgery, moderate/severe preoperative anaemia (aOR 1.61, p = 0.04) and high preoperative RDW levels in the 3rd quartile (>13.4% and ≤14.3%) and 4th quartile (>14.3%) were significantly associated with increased odds of 30-day mortality - (aOR 2.12, p = 0.02) and (aOR 2.85, p = 0.001) respectively, after adjusting for the effects of transfusion, surgical severity, priority of surgery, and comorbidities. Patients with high RDW, defined as >15.7% (90th centile), and preoperative anaemia have higher odds of 30-day mortality compared to patients with anaemia and normal RDW. Thus, preoperative RDW independently increases risk of 30-day postoperative mortality, and future risk stratification strategies should include RDW as a factor.

Methotrexate therapy impacts on red cell distribution width and its predictive value for cardiovascular events in patients with rheumatoid arthritis

BACKGROUND

Methotrexate (MTX) is well known to affect folic acid metabolism, so MTX treatment can result in alterations of mean corpuscular volume (MCV), which may impact on red cell distribution width (RDW), as MCV levels feed into RDW calculation. We thus questioned whether RDW levels and subsequently its diagnostic utility in RA subjects, as reported before, are influenced by ongoing MTX therapy.We assessed the impact of disease modifying drug (DMARD) treatment, especially MTX, on RDW and evaluated their influence on the predictive value of RDW for cardiovascular (CV) events in patients with rheumatoid arthritis (RA). As far as we know, this is the first study evaluating the influence of MTX on RDW.

METHODS

Medical treatment, disease activity, laboratory parameters and history of CV events were retrospectively analysed in 385 RA patients at disease onset and at last follow up at our clinic. Additionally, in patients with CV event, data were recorded at last follow up prior the CV event.

RESULTS

Disease parameters and laboratory findings associated with a serious vascular event were older age (p < 0,001), longer disease duration (p = 0,002) and a higher RDW at diagnosis (p = 0,025). No differences in RDW levels became evident with any other treatment regimen beside MTX. MTX treated patients had significantly higher RDW compared to subjects without this drug (p < 0,001). In RA patients without MTX treatment, we found RDW level significantly different between those with versus without a CV event, whereas this difference disappeared in subjects receiving MTX.

CONCLUSION

MTX impacts on RDW and might therefor reduce its prognostic value for CV events in patients taking MTX, whereas an increased RDW at diagnosis remains an early risk predictor for myocardial infarction and stroke in RA patients.

Red Blood Cell Distribution Width Can Predict Vasculitis Activity and Poor Prognosis in Granulomatosis with Polyangiitis

PURPOSE

We investigated whether red blood cell distribution width (RDW) predicts vasculitis activity based on Birmingham vasculitis activity score (BVAS) or BVAS for granulomatosis with polyangiitis (GPA) at diagnosis and poor prognosis during follow-up in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

MATERIALS AND METHODS

We reviewed the medical records of 150 patients with AAV. We defined severe GPA as BVAS for GPA ≥7 (the highest quartile). Correlation and standardised correlation coefficients were analysed by linear regression tests. The differences between groups were evaluated by Mann-Whitney test. Relative risk (RR) was assessed by chi square test and Cox hazards model.

RESULTS

RDW was correlated only with the vasculitis activity of GPA among patients with AAV. An increase in RDW was associated with the absence of ear nose throat (ENT) manifestation, but not proteinase 3-ANCA. Significant differences were noted in cumulative refractory free survival according to RDW ≥15.4% (p=0.007) and the absence of ENT manifestation (p=0.036). Multivariate Cox hazards analysis identified RDW ≥15.4% as the only significant predictor of refractory disease in GPA (RR 17.573).

CONCLUSION

RDW predicts vasculitis activity in GPA, and RDW ≥15.4% at diagnosis may increase the risk of severe GPA at diagnosis and predict refractory diseases during follow-up.

Biological pathways underlying the association of red cell distribution width and adverse clinical outcome: Results of a prospective cohort study

Background

Red cell distribution width (RDW) predicts disease outcome in several patient populations, but its prognostic value in addition to other disease parameters in unselected medical inpatients remains unclear. Our aim was to investigate the association of admission RDW levels and mortality adjusted for several disease pathways in unselected medical patients from a previous multicenter study.

Methods

We included consecutive adult, medical patients at the time point of hospital admission through the emergency department into this observational, cohort study. The primary endpoint was mortality at 30-day. To study association of admission RDW and outcomes, we calculated regression analysis with step-wise inclusion of clinical and laboratory parameters from different biological pathways.

Results

The 30-day mortality of the 4273 included patients was 5.6% and increased from 1.4% to 14.3% from the lowest to the highest RDW quartile. There was a strong association of RDW and mortality in unadjusted analysis (OR 1.32; 95%CI 1.27–1.39, p<0.001). RDW was strongly correlated with different pathways including inflammation (coefficient of determination (R²) 0.30; p<0.001), nutrition (R² 0.20; p<0.001) and blood diseases (R² 0.30; p<0.001 The association was eliminated after including different biological pathways into the models with the fully adjusted regression model showing an OR of 1.02 (95%CI 0.93–1.12; p = 0.664) for the association of RDW and mortality. Similar effects were found for other outcomes including intensive care unit admission and hospital readmission.

Conclusion

Our data suggests that RDW is a strong surrogate marker of mortality in unselected medical inpatients with most of the prognostic information being explained by other disease factors. The strong correlation of RDW and different biological pathways such as chronic inflammation, malnutrition and blood disease suggest that RDW may be viewed as an unspecific and general “chronic disease prognostic marker”.

Red cell distribution width associated with adverse cardiovascular outcomes in patients with chronic kidney disease

Background

Recent studies have demonstrated that red cell distribution width (RDW) is associated with cardiovascular (CV) events and mortality. Patients with chronic kidney disease (CKD) are often anemic and have high RDW levels. In this study, we investigated the effect of RDW on major composite CV outcomes among patients with CKD.

Methods

We retrospectively analyzed patients with CKD who were admitted to the department of cardiology of a tertiary hospital in 2011. The patients were divided into 2 groups: normal RDW (RDW < 14.5%) and elevated RDW (RDW ≥ 14.5%). Demographic characteristics, comorbidities, blood investigation results, prescriptions, and outcomes were analyzed after a 3-year follow-up period. Six adjustment levels were performed to evaluate the effect of RDW on outcomes.

Results

This study involved 282 patients with CKD: 213 in the elevated RDW group and 69 in the normal RDW group. The elevated RDW group had older patients, a lower proportion of male patients, lower left ventricular ejection fraction (LVEF) values, lower hemoglobin levels, lower serum albumin levels, and higher creatinine levels, compared with the normal RDW group. A linear trend was observed toward higher RDW in patients with deteriorating renal function. In the final adjusted model, RDW ≥ 14.5%, older age, and lower LVEF were associated with an increased risk of major composite CV outcomes.

Conclusion

RDW is a potentially useful cost-effective indicator of major composite CV outcomes in patients with CKD.

Red blood cell distribution width is associated with mortality in elderly patients with sepsis

INTRODUCTION

RDW is a prognostic biomarker and associated with mortality in cardiovascular disease, stroke and metabolic syndrome. For elderly patients, malnutrition and multiple comorbidities exist, which could affect the discrimination ability of RDW in sepsis. The main purpose of our study was to evaluate the prognostic value of RDW in sepsis among elderly patients.

METHODS

This was a retrospective cohort study conducted in emergency department intensive care units (ED-ICU) between April 2015 and November 2015. Elderly patients (≥65years old) who were admitted to the ED-ICU with a diagnosis of severe sepsis and/or septic shock were included. The demographic data, biochemistry data, qSOFA, and APACHE II score were compared between survivors and nonsurvivors.

RESULTS

A total of 117 patients was included with mean age 81.5±8.3years old. The mean APACHE II score was 21.9±7.1. In the multivariate Cox proportional hazards model, RDW level was an independent variable for mortality (hazard ratio: 1.18 [1.03-1.35] for each 1% increase in RDW, p=0.019), after adjusting for CCI, any diagnosed malignancy, and eGFR. The AUC of RDW in predicting mortality was 0.63 (95% confidence interval [CI]: 0.52-0.74, p=0.025). In subgroup analysis, for qSOFA <2, nonsurvivors had higher RDW levels than survivors (17.0±3.3 vs. 15.3±1.4%, p=0.044).

CONCLUSIONS

In our study, RDW was an independent predictor of in-hospital mortality in elderly patients with sepsis. For qSOFA scores <2, higher RDW levels were associated with poor prognosis. RDW could be a potential parameter used alongside the clinical prediction rules.