CBC Biomarkers: Red Cell Distribution Width (RDW)

Optimal Takeaways

The red cell distribution width (RDW) indicates whether there is a wide variation in the size of RBCs in circulation. Measurement of RDW assists in assessing anemia as well as cancer prognosis. Elevated RDW is also seen with cardiometabolic disease and inflammation and is often associated with nutritional deficiencies.

Standard Range: 11 - 15%

The ODX Range: 11 - 12.6%    

Low RDW suggests uniformity in red blood cell width.

High RDW is associated with hemolytic anemias, posthemorrhagic anemia, hemoglobinopathies, and nutritional deficiency of iron, B12, or folate. Elevated RDW may also be observed in myelodysplastic syndrome, cancer, autoimmunity, chronic liver disease, metabolic syndrome, single nucleotide polymorphisms, blood transfusions, peripheral artery disease, ischemic heart disease, hypertension, and elevated inflammatory biomarkers, including CRP, fibrinogen, WBCs (Fava 2019).

Increased RDW is associated with smoking and heart disease risk (Gang 2016), increased coronary artery calcification score/CACS (Gürel 2015), inflammation, poorer cancer prognosis (Ai 2018), heart failure, diabetes (Xanthopoulos 2017), elevated CRP and erythrocyte sedimentation rate, fatal and non-fatal cardiovascular events (Lippi 2009), and celiac disease (Goyal 2017).

Overview

Red cell distribution width reflects variations in the size of RBCs in circulation and is based on RBC and MCV values. It is useful in the classification of different types of anemias. Red blood cells are normally uniform in size, and a wide variation is associated with a condition called anisocytosis. Mounting evidence demonstrates an association between increased RDW and chronic disease including cardiovascular disease, diabetes, and cancer.

A comprehensive review of the literature found that elevated RDW was associated with biomarkers of inflammation (CRP, fibrinogen, WBCs), metabolic syndrome, dyslipidemia, CVD mortality, ischemic heart disease, hypertension, peripheral artery disease, and diabetes mellitus (Fava 2019).

An increased risk of diabetes was observed in a retrospective study of 2,688 individuals as RDW rose above 12.2% (Gang 2016). In a prospective cohort study of 29,526 coronary angiography patients, the lowest rate of incident mortality was found in those with an RDW of 12.6% or less (Anderson 2007).

During the follow-up of a large prospective study of 25,612, researchers noted that a 1% increase in RDW was associated with a 16% increased risk of a first myocardial infarction, even after adjusting for several variables and excluding those with anemia. An RDW above 13.7% was associated with a 69% greater risk of a first MI than those with an RDW of 10.7-12.2% (Skjelbakken 2014). Researchers hope to utilize RDW to help predict and prevent cardiovascular disease and cerebrovascular events (Li 2017).

RDW is considered a prognostic biomarker for both acute and chronic heart failure. In one prospective cohort study of 218 acute heart failure patients, the mean RDW was 15.3% for those with heart failure and diabetes, and 15.2% with heart failure but no diabetes. Researchers noted a 34.9% increased risk of all-cause mortality, or readmission for heart failure, for each 1% increase in RDW (Xanthopoulos 2017).

A higher RDW may be associated with a poorer prognosis in cancer, including lung, breast, prostate, gastrointestinal, and hematological cancers. A meta-analysis of 7 studies comprising 1,031 subjects with hematological cancers, e.g., leukemia, lymphoma, and multiple myeloma, observed decreased survival as RDW rose above 14% (Ai 2018). Researchers note that RDW abnormalities may be related to the role that inflammation plays in impairing erythropoiesis.

A review of data from 8,175 individuals 45 years and older found that all-cause mortality risk was significantly increased with a higher RDW, even without iron, folate, or B12 deficiencies. All-cause mortality increased by 22% for every 1% increase above 12.6%. Those with a higher RDW were more likely to be older, actively smoking, less educated, and have a higher BMI. Additional research indicated that mortality doubled for those with an RDW above 15.5% compared to below 13% (Patel 2009).

References

Ai, L., Mu, S., & Hu, Y. (2018). Prognostic role of RDW in hematological malignancies: a systematic review and meta-analysis. Cancer cell international, 18, 61. https://doi.org/10.1186/s12935-018-0558-3

Anderson, Jeffrey L et al. “Usefulness of a complete blood count-derived risk score to predict incident mortality in patients with suspected cardiovascular disease.” The American journal of cardiology vol. 99,2 (2007): 169-74. doi:10.1016/j.amjcard.2006.08.015

Fava, Cristiano et al. “The role of red blood cell distribution width (RDW) in cardiovascular risk assessment: useful or hype?.” Annals of translational medicine vol. 7,20 (2019): 581. doi:10.21037/atm.2019.09.58

Gang, Li, and Wan Lifang. “Association of the Elevated Red Blood Cell Distribution Width with the Risk of Developing Diabetes Mellitus.” Internal medicine (Tokyo, Japan) vol. 55,15 (2016): 1959-65. doi:10.2169/internalmedicine.55.5956

Goyal, Hemant et al. “Prognostic significance of red blood cell distribution width in gastrointestinal disorders.” World journal of gastroenterology vol. 23,27 (2017): 4879-4891. doi:10.3748/wjg.v23.i27.4879

Gürel, Ozgul Malcok et al. “Association between Red Blood Cell Distribution Width and Coronary Artery Calcification in Patients Undergoing 64-Multidetector Computed Tomography.” Korean circulation journal vol. 45,5 (2015): 372-7. doi:10.4070/kcj.2015.45.5.372

Li, Ning et al. “Red Blood Cell Distribution Width: A Novel Predictive Indicator for Cardiovascular and Cerebrovascular Diseases.” Disease markers vol. 2017 (2017): 7089493. doi:10.1155/2017/7089493

Lippi, Giuseppe et al. “Relation between red blood cell distribution width and inflammatory biomarkers in a large cohort of unselected outpatients.” Archives of pathology & laboratory medicine vol. 133,4 (2009): 628-32. doi:10.5858/133.4.628

May, J. E., Marques, M. B., Reddy, V., & Gangaraju, R. (2019). Three neglected numbers in the CBC: The RDW, MPV, and NRBC count. Cleveland Clinic journal of medicine, 86(3), 167–172. https://doi.org/10.3949/ccjm.86a.18072

Patel, Kushang V et al. “Red blood cell distribution width and the risk of death in middle-aged and older adults.” Archives of internal medicine vol. 169,5 (2009): 515-23. doi:10.1001/archinternmed.2009.11

Skjelbakken, Tove et al. “Red cell distribution width is associated with incident myocardial infarction in a general population: the Tromsø Study.” Journal of the American Heart Association vol. 3,4 e001109. 18 Aug. 2014, doi:10.1161/JAHA.114.001109

Xanthopoulos, Andrew et al. “Red blood cell distribution width as a prognostic marker in patients with heart failure and diabetes mellitus.” Cardiovascular diabetology vol. 16,1 81. 6 Jul. 2017, doi:10.1186/s12933-017-0563-1