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. 2025 Apr 17;20(4):e0321789.
doi: 10.1371/journal.pone.0321789. eCollection 2025.

The red blood cell distribution width is associated with all-cause and cardiovascular mortality among individuals with non-alcoholic fatty liver disease

Yingxiu Huang  1 , Ting Ao  1 , Yinying Wang  1 , Peng Zhen  1 , Ming Hu  1
Affiliations

The red blood cell distribution width is associated with all-cause and cardiovascular mortality among individuals with non-alcoholic fatty liver disease

Yingxiu Huang et al. PLoS One. .

Abstract

Background: Identifying reliable prognostic indicators is essential for the appropriate management of non-alcoholic fatty liver disease (NAFLD). Red blood cell distribution width (RDW) has been established as an inflammatory marker associated with cardiovascular outcomes. This study aimed to evaluate the association between RDW and both cardiovascular and all-cause mortality in individuals with NAFLD.

Methods: Data from 7,438 participants with NAFLD were analyzed, collected between 2005 and 2016 through the National Health and Nutrition Examination Survey (NHANES). Mortality data were retrieved from the National Death Index (NDI). Restricted cubic spline (RCS) analysis was used to illustrate the relationship between RDW and mortality risk, Weighted Cox proportional hazards models were used to assess the independent relationship between RDW and mortality risk. Receiver operating characteristic (ROC) curves were generated to evaluate the predictive ability of RDW for survival outcomes.

Results: During a median follow-up period of 124 months, 1,269 deaths were recorded, including 335 from cardiovascular causes. RDW positively correlated with both cardiovascular and all-cause mortality according to the RCS analysis. Participants were categorized into quartiles based on RDW levels. Those in the highest RDW quartile (Q4) demonstrated a significantly higher risk of cardiovascular mortality (HR 3.61, 95% confidence interval [CI]:2.17-6.02, P=0.009) and all-cause mortality (HR 2.29, 95% CI:1.72-3.06, P < 0.0001), according to the weighted Cox hazards models. Additionally, the area under the curve (AUC) for all-cause mortality at 3, 5 and 10 years was, 0.69, 0.67, and 0.66, respectively. For cardiovascular mortality, the AUCs were 0.70, 0.68, and 0.68, respectively.

Conclusion: Among patients with NAFLD, RDW was identified as an independent predictor of increased cardiovascular and all-cause mortality risk.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Flowchart of study.
Fig 2
Fig 2. The relationship between RDW and both all-cause
(A) and cardiovascular mortality (B) in individuals with NAFLD is depicted using restricted cubic splines. The hazard ratios were adjusted for various factors, including age, sex, race, BMI, smoking status, education level, diabetes, history of CVD.
Fig 3
Fig 3. Kaplan–Meier survival curves stratified by RDW quartiles, depicting survival rates for all-cause mortality
(A) and cardiovascular mortality (B).
Fig 4
Fig 4. Subgroup analysis across various factors of the association between RDW with all-cause mortality
(A) and cardiovascular mortality (B). subgroup analysis across various factors, including smoking status, age, BMI, sex, CVD, and diabetes.
Fig 5
Fig 5. Time-dependent ROC curves and corresponding AUC values, along with 95% confidence intervals, for RDW in predicting all-cause mortality
(A, B) and cardiovascular mortality (C, D).
See this image and copyright information in PMC

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