We have read the study about the association between high red blood cell distribution width and higher ward mortality after intensive care unit discharge. The study increases the evidence that RDW may be a marker of severity for patients discharged from the ICU. However, in this letter, we comment on issues that need further discussion

Boniatti, Márcio Manozzo

Faulhaber, Gustavo Adolpho Moreira

Lisboa, Thiago Costa

Tonietto, Tiago Antônio

Viana, Marina Verçoza

Journal of Critical Care

English

Lume 5.8

LETTER TO THE EDITOR Open AccessIs red blood cell distribution width amarker of severity in patients dischargedfrom the ICU?Tiago Antonio Tonietto1,2* , Marcio Manozzo Boniatti2, Thiago Costa Lisboa2, Marina Verçoza Viana2 andGustavo Adolpho Moreira Faulhaber3AbstractWe have read the study about the association between high red blood cell distribution width and higher wardmortality after intensive care unit discharge. The study increases the evidence that RDW may be a marker of severity forpatients discharged from the ICU. However, in this letter, we comment on issues that need further discussion.Keywords: Red blood cell distribution width, RDW, Intensive care unit, MortalityDear Editor,We read with interest the retrospective study byFernandez and colleagues entitled “High red blood celldistribution width as a marker of mortality after ICU dis-charge: a cohort study” [1]. The authors evaluated the as-sociation between the red blood cell distribution width(RDW) with ward survival after intensive care unit (ICU)discharge and whether the RDW could improve the accur-acy of the Sabadell score, a subjective tool designed tostratify patients according to ward mortality after ICU dis-charge. They showed that high RDW (defined as greaterthan 14.5%) was associated with increased ward mortality(multivariable OR 2.8 [1.7–4.6]) and longer ward stay.Additionally, high RDW identified patients with higherward mortality at each level of prognosis depicted by theSabadell score, except for score 3 group. This interestingstudy increases the evidence that the RDW may be amarker of severity for patients discharged from the ICU.However, there are issues that need further discussion.Firstly, in the methods section, it is stated that routinelaboratory was requested by the attending physician asclinically required and the authors used the last recordedRDW before discharge to the ward. However, in theresults, there should have been a description of the meantime between the RDW collection and the moment ofICU discharge. This is specially important because themedian ICU length of stay was < 3.5 days and the authorsdid not adjust their results for the RDW collected in theICU admission. Thus, the ward mortality could be relatedto high RDW at ICU admission and not at ICU discharge.The worst outcomes associated with the former havealready been demonstrated in other studies [2].Additionally, it would be interesting if the authors hadreported the variation between the RDW collected atICU discharge and ICU admission. Few studies haveassessed the kinetics of the RDW and its prognosticvalue throughout hospitalization [3, 4]. Our group de-scribed that patients readmitted to the ICU or who diedin the ward had a significantly more pronounced in-crease in RDW during their ICU stay than other patients(median = 0.5% and 0.2%, respectively; p = 0.02) [5].Lastly, we have also demonstrated that high RDW is amarker of severity in patients discharged from the ICUto the wards [5]. We illustrated that patients with ele-vated RDW at ICU discharge had a significantly higherrisk of ICU readmission or unexpected death in wardthan patients with normal RDW (HR 1.901; 95% CI1.357–2.662), even after adjusting for the RDW at ICUadmission and several known risk factors associated withthis outcome. Furthermore, elevated RDW at dischargefrom the ICU was also associated with hospital mortality(HR 1.716; 95% CI 1.141–2.580).* Correspondence: ttonietto@hcpa.edu.br1Department of Critical Care Medicine, Hospital Nossa Senhora da Conceição,596 Francisco Trein Ave, Porto Alegre, RS 91350-200, Brazil2Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre,2350 Ramiro Barcelos Street, Porto Alegre, RS 90035-903, BrazilFull list of author information is available at the end of the article© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Tonietto et al. Journal of Intensive Care             (2019) 7:6 https://doi.org/10.1186/s40560-019-0364-6Finally, practical implications of these findings includedeveloping clinical prediction rules that considerthe RDW as a relevant variable at ICU discharge. Theimpact of recognition of the RDW as a risk factor, lead-ing to closer monitoring of these patients in wards, willdepend on further studies assessing specificinterventions.AbbreviationsHR: Hazard ratio; ICU: Intensive care unit; OR: Odds ratio; RDW: Red blood celldistribution widthAcknowledgementsNone.FundingNot applicableAvailability of data and materialsNot applicable.Author’s contributionsAll authors participated in the preparation and writing of the manuscript. Allauthors read and approved the final manuscript.Ethics approval and consent to participateNot applicableConsent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Department of Critical Care Medicine, Hospital Nossa Senhora da Conceição,596 Francisco Trein Ave, Porto Alegre, RS 91350-200, Brazil. 2Department ofCritical Care Medicine, Hospital de Clínicas de Porto Alegre, 2350 RamiroBarcelos Street, Porto Alegre, RS 90035-903, Brazil. 3Department of InternalMedicine, School of Medicine, Universidade Federal do Rio Grande do Sul,721 Jeronimo de Ornelas Ave, Porto Alegre, RS 90040-341, Brazil.Received: 26 December 2018 Accepted: 22 January 2019References1. Fernandez R, Cano S, Catalan I, Rubio O, Subira C, Masclans J, et al. High redblood cell distribution width as a marker of hospital mortality after ICUdischarge: a cohort study. J Intensive Care. 2018;6:74.2. Bazick HS, Chang D, Mahadevappa K, Gibbons FK, Christopher KB. Red celldistribution width and all-cause mortality in critically ill patients. Crit CareMed. 2011;39(8):1913–21.3. Kim CH, Park JT, Kim EJ, Han JH, Han JS, Choi JY, et al. An increase in redblood cell distribution width from baseline predicts mortality in patientswith severe sepsis or septic shock. Critical care (London, England). 2013;17(6):R282.4. Zhang Z, Xu X, Ni H, Deng H. Red cell distribution width is associated withhospital mortality in unselected critically ill patients. J Thorac Dis. 2013;5(6):730–6.5. Tonietto TA, Boniatti MM, Lisboa TC, Viana MV, Dos Santos MC, Lincho CS, et al.Elevated red blood cell distribution width at ICU discharge is associated withreadmission to the intensive care unit. Clin Biochem. 2018;55:15–20.Tonietto et al. 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Is red blood cell distribution width a marker of severity in patients discharged from the ICU?

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Is red blood cell distribution width a marker of severity in patients discharged from the ICU?

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