Association of Admission Red Cell Distribution Width with Outcome in Acute Liver Failure

Abstract

Purpose: The goal of this retrospective case series was to evaluate the association of admission RDW with outcome in acute liver failure. Methods: 205 consecutive patients with acute liver injury/failure (ALI/ALF) were enrolled in the ALF Study Group Registry from Virginia Commonwealth University Medical Center between July, 2001 and September, 2011. Admission RDW was retrospectively collected and analyzed for association with outcome of hospital admission. Outcome of admission was recorded as transplant free survival (TFS), transplant, or mortality. Results: Of the 205 patients, 158 had ALF, 47 had ALI. TFS was observed in 122 patients (59%), death in 65 (31%) and liver transplantation in 21 (10%). TFS was strongly associated with lower admission INR (P=0.0007), total bilirubin, phosphate, venous ammonia, lactate, PTT, and RDW (all P<0.0001). Death or liver transplantation was observed in 18 of 85 patients (21%) with normal RDW (≤14.1%), 21 of 47 patients (45%) with moderately elevated RDW (14.6-15.9%), and 44 of 73 patients (60%) with markedly elevated RDW (≥16.0%) on admission to the hospital (P <0.0001). For TFS, the area under the receiver operating characteristic curve for admission RDW was 0.700, and was greater than for INR (0.647). Conclusion: In this retrospective case series, an elevation in admission RDW is associated with increased risk of transplant or mortality in ALF. ALF is a prototypical syndrome of intense systemic inflammatory response, which results in multi-organ system failure, and often death. The relationship between high RDW and poor outcome remains undefined. Concentrations of key proinflammatory cytokines involved in the propagation of the ALF syndrome (TNFα, IL-1β, and IL-6) have been proposed to increase RDW. We hypothesize that the association between high RDW and poor outcome in ALF reflects increased pro-inflammatory cytokines and systemic inflammation. As RDW is routinely gathered and automatically calculated as part of the complete blood count, it may provide additional prognostic data to the physician at no additional cost. Understanding how this measure is associated with outcome may provide new insight into the pathophysiology of acute liver failure.Figure: No Caption available.