Patients of rheumatoid arthritis, who were already diagnosed as per 2010 ACR / EULAR ( American college of Rheumatology / European League Against Rheumatism ) classification criteria were included in the study. Red cell band width was determined in all the patients from laboratory of own hospital. Severity of rheumatoid arthritis was determined on the basis of Disease Activity Score-28 (DAS-28). Age, gender, duration of rheumatoid arthritis and red cell band width were correlated with the severity of rheumatoid arthritis.
Mean age of the study participants was 36.37±7.822 years. 187 (74.8%) patients were female while 63 (25.2%) were male. 99 (39.6%) patients had mild activity disease, 115 (46%) had moderate while 36 (14.4%) had severe activity of illness. 137 (54.8%) had red cell band width within normal range while 113 (45.2%) had increased with. Pearson chi-square test revealed that increasing age, long duration of illness and increased red cell band width had a statistically significant association with severity of illness among the patients suffering from rheumatoid arthritis (p-value 3.2 — ≤ 5.1, and High disease activity: DAS-28 >5.1 13
Statistical analysis was performed by using the SPSS 23.0. Frequency and percentage were calculated for the qualitative variables like gender, patients with mild, moderate or severe activity of disease or patients with and without the increased red cell band width. Mean and standard deviation was calculated for the age of the patients and duration of illness. Pearson chi-square test was used to see the association between the age, gender, presence of increased RDW and duration of RA with the severity of illness. p-value less than or equal to 0.05 was considered as significant for this study.
Two hundred and fifty patients of rheumatoid arthritis were recruited in the analysis after inclusion and exclusion criteria were applied. Mean age of the study participants was 36.37±7.822 years. Mean duration of rheumatoid arthritis among the study participants was 3.57±6.125 years. Table I shows that 187 (74.8%) patients were female while 63 (25.2%) were male. 99 (39.6%) patients had mild activity disease, 115 (46%) had moderate while 36 (14.4%) had severe activity of illness. 137 (54.8%) and red cell band width within normal range while 113 (45.2%) had increased with. Pearson chi-square test (Table II) revealed that increasing age, long duration of illness and increased red cell band width had a statistically significant association with severity of illness among the patients suffering from rheumatoid arthritis (p-value 0.05).
Rheumatology is an emerging specialty in our country with limited number of trained doctors available to manage a huge number of patients which mostly rely on the general practitioners or the medial specialists. Adequate knowledge about all the aspects of rheumatology diseases can only enable the doctors to manage the patients effectively and screen and pick up the cases with advanced disease early for aggressive management plan. Various immune based or blood indices have been used in the diagnosis and prediction of severity of illness in rheumatoid arthtiirs.3-5 We planned this study with the rationale to determine the correlation between red cell band width and disease severity in patients suffering from rheumatoid arthritis presenting to our teaching hospital from all parts of the country.
Lee et al. in 2010 published an interesting study and concluded that RDW has a strong association with the presence and severity of rheumatoid arthritis. It has also been linked to raised CRP among the target population.14 Our findings were quite similar to them as RDW has strong association with more severe diseases in our study population. Our scope was limited so we did not study correlation of other parameters like CRP and ESR.
Salvagno et al. in 2015 and Patel et al. in 2018 published that an increased RDW mirrors a profound deregulation of erythrocyte homeostasis involving both impaired erythropoiesis and abnormal red blood cell survival, which may be attributed to a variety of underlying metabolic abnormalities such as shortening of telomere length, oxidative stress, inflammation, poor nutritional status, dyslipidemia, hypertension, erythrocyte fragmentation and alteration of erythropoietin function.15,16Our findings also suggest that RDW should be incorporated when a patient of RA is investigated because it can predict the severity of illness.
Rodríguez-Carrio et al. in 2015 did a very interesting study and incorporated the cardiovascular risk in addition to severity of RA in their study design and came up with the findings that RDW at disease onset may be used as an early marker of CV risk in RA, whereas in patients with established disease it was related to the activity of the disease. These findings suggest that RDW can be considered as a surrogate marker of inflammation and, consequently, CV risk in RA patients.17Our results supported their results from the point of view that RDW predicted disease severity in our study. For cardiovascular risk factors prediction studies with a longitudinal design need to be conducted in local population to fill the gap. Same authors in same year published another study highlighting the underlying mechanism that RDW was associated to Endothelial Progenitor Cells (EPC) depletion and increased levels of different mediators linked to endothelial damage and vascular repair failure, thereby shedding new light on the nature of RDW as cardiovascular and disease severity predictor.18
Lin et al. in 2018 and Yunchun et al. in 2016 performed studies with a similar design as that of ours and came up with the similar results that RDW had a strong link with presence of active inflammation and more severe disease among the patients suffering from RA.7,8Our results were similar to their results and showed that this phenomenon has not been different in our population and with more studies we could be able to make our local guidelines to incorporate this parameter in routine investigation of RA.
Small sample size, cross-sectional study design, ample population from a single center and lack of availability of RDW values prior to the onset of RA or at the time of diagnosis of RA are some of the limitations which need to be addressed in future studies to generate the results which could be generalized to the local population.
Considerable number of patients suffering from rheumatoid arthritis had severe form of illness. Increased red cell band width emerged as a predictor of severe form of illness among the study participants in addition to the advancing age of patient and long duration of illness.
- Dargham SR, Zahirovic S, Hammoudeh M, et al. Epidemiology and treatment patterns of rheumatoid arthritis in a large cohort of Arab patients [published correction appears in PLoS One. 2019 Mar 18;14(3):e0214258]. PLoS One. 2018;13(12):e0208240. Published 2018 Dec 19. doi:10.1371/journal.pone.0208240
- Naqvi AA, Hassali MA, Aftab MT. Epidemiology of rheumatoid arthritis, clinical aspects and socio-economic determinants in Pakistani patients: A systematic review and meta-analysis. J Pak Med Assoc. 2019;69(3):389-398.
- Guo Q, Wang Y, Xu D, Nossent J, Pavlos NJ, Xu J. Rheumatoid arthritis: pathological mechanisms and modern pharmacologic therapies. Bone Res. 2018;6:15. Published 2018 Apr 27. doi:10.1038/s41413-018-0016-9
- Edwards CJ, Kiely P, Arthanari S, et al. Predicting disease progression and poor outcomes in patients with moderately active rheumatoid arthritis: a systematic review. Rheumatol Adv Pract. 2019;3(1):rkz002. Published 2019 Feb 15. doi:10.1093/rap/rkz002
- Said AS, Spinella PC, Hartman ME, et al. RBC Distribution Width: Biomarker for Red Cell Dysfunction and Critical Illness Outcome?. Pediatr Crit Care Med. 2017;18(2):134–142. doi:10.1097/PCC.0000000000001017
- Bazick HS, Chang D, Mahadevappa K, Gibbons FK, Christopher KB. Red cell distribution width and all-cause mortality in critically ill patients. Crit Care Med. 2011;39(8):1913–1921. doi:10.1097/CCM.0b013e31821b85c6
- Lin F, Wang X, Liang Y, Liu D, Zhang Y, Zhong R, Yang Z. Red Blood Cell Distribution Width in Rheumatoid Arthritis, Ankylosing Spondylitis and Osteoarthritis: True Inflammatory Index or Effect of Anemia? Ann Clin Lab Sci. 2018;48(3):301-307.
- Yunchun L, Yue W, Jun FZ, Qizhu S, Liumei D. Clinical Significance of Red Blood Cell Distribution Width and Inflammatory Factors for the Disease Activity in Rheumatoid Arthritis. Clin Lab. 2016;62(12):2327-2331. doi: 10.7754/Clin.Lab.2016.160406.
- Horta-Baas G, Romero-Figueroa MDS. Clinical utility of red blood cell distribution width in inflammatory and non-inflammatory joint diseases. Int J Rheum Dis. 2019 ;22(1):47-54. doi: 10.1111/1756-185X.13332.
- Hameed K, Gibson T. A comparison of the prevalence of rheumatoid arthritis and other rheumatic diseases amongst Pakistanis living in England and Pakistan. Br J Rheumatol. 1997 ;36(7):781-5.
- Aletaha D, Smolen JS. Diagnosis and Management of Rheumatoid Arthritis: A Review. JAMA. 2018;320(13):1360-1372. doi: 10.1001/jama.2018.13103.
- Sarma PR. Red Cell Indices. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 152. Available from: https://www.ncbi.nlm.nih.gov/books/NBK260/
- Barczyńska TA, Dura M, Blumfield E, et al. DAS28 score vs. ultrasound examination for assessment of rheumatoid arthritis disease activity: comparison and discussion of pros and cons. Reumatologia. 2015;53(4):213–218. doi:10.5114/reum.2015.53999
- Lee WS, Kim TY. Relation Between Red Blood Cell Distribution Width and Inflammatory Biomarkers in Rheumatoid Arthritis. Arch of Path and Lab Med. 2010;134(4):505-506.
- Salvagno GL, Sanchis-Gomar F, Picanza A, Lippi G. Red blood cell distribution width: A simple parameter with multiple clinical applications. Crit Rev Clin Lab Sci. 2015;52(2):86-105. doi: 10.3109/10408363.2014.992064
- Patel KV, Semba RD, Ferrucci L, et al. Red cell distribution width and mortality in older adults: a meta-analysis. J Gerontol A Biol Sci Med Sci. 2010;65(3):258–265. doi:10.1093/gerona/glp163
- Rodríguez-Carrio J, Alperi-López M, López P, Alonso-Castro S, Ballina-García FJ, Suárez A. Red cell distribution width is associated with cardiovascular risk and disease parameters in rheumatoid arthritis. Rheumatology (Oxford). 2015;54(4):641-6. doi: 10.1093/rheumatology/keu345.
- Rodríguez-Carrio J, Alperi-López M, López P, Alonso-Castro S, Carro-Esteban SR, Ballina-García FJ et al. cell distribution width is associated with endothelial progenitor cell depletion and vascular-related mediators in rheumatoid arthritis. Atherosclerosis. 2015;240(1):131-6. doi: 10.1016/j.atherosclerosis.2015.03.009