U-shaped association between hemoglobin to red blood cell distribution width ratio and all-cause mortality among critically ill pediatric patients

Sep 30, 2026

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Objective: Determine whether the lower hemoglobin to red blood cell distribution width ratio (HRR) predicts adverse course in pediatric intensive care, where its link to all-cause mortality remains unclear. Methods: Retrospective cohort analysis of the Pediatric Intensive Care Unit (PICU) database from 2010–2018; HRR was computed from first-24-hour labs. Primary endpoint was 28-day in-hospital all-cause mortality. Multivariable logistic regression with restricted cubic splines and threshold-effect analysis evaluated dose–response patterns and potential interactions.

LanguageEnglish

CategoryHealthcare

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Introduction

Jornal de Pediatria 2026;102(1): 101491 [www.jped.com.br](www.jped.com.br) ORIGINAL ARTICLE U-shaped association between hemoglobin to red blood cell distribution width ratio and all-cause mortality among critically ill pediatric patients Weichao He a,* , Jie Liu b, Rui Jiang c, Xinyu Yang d, Xujie Zhang e, Ruoyu Cao a, Zhenshui Hu d, Xiaolan Zhang f, Yan Gao g a Cangzhou Central Hospital, Department of Pediatrics, Cangzhou, Hebei Province, China b Chinese PLA General Hospital, Department of Vascular and Endovascular Surgery, Beijing, China c Cangzhou Central Hospital, Department of Neonatology, Cangzhou, Hebei Province, China d Blood Transfusion Research Laboratory, Cangzhou Central Blood Station, Cangzhou, Hebei Province, China e Chinese Medicine Hall, Cangzhou Central Hospital, Cangzhou, Hebei Province, China f Third People ’s Hospital of Liaocheng, Department of Pediatrics, Liaocheng, Shandong Province, China g The 960th Hospital of PLA, Department of General Medicine, JiNan, ShanDong Province, China Received 11 July 2025; accepted 28 November 2025 Available online xxx KEYWORD Hemoglobin and red blood cell distribution width (HRR); Mortality; Cohort study; Pediatric Intensive Care Unit (PIC) database Abstract Objective: The lower hemoglobin to red blood cell distribution width ratio (HRR) is associated with an increased risk of mortality in adult patients, but its relationship with clinical progress in the Pediatric Intensive Care Unit (PICU) is unclear. The authors aimed to investigate the association between HRR and all-cause mortality among pediatric patients. Methods: The authors conducted a retrospective cohort study by analyzing the PIC database from 2010 to 2018.HRR was calculated based on laboratory tests conducted within the ﬁrst 24 hours of PICU admission. The primary outcome was 28-day in-hospital all-cause mortality. Multivariable logistic regression models, restricted cubic spline, and threshold effects analysis were applied to assess the relationship between HRR and mortality in this cohort. Results: A total of 8015 patients with an average age of the participants was1.5 (0.4, 4.8) years, and 3547 (44.3%) individuals were female. The 28-day in-hospital all-cause mortality was 4.1%(330/8015) . The relationship between HRR and mortality was U-shaped, which had a threshold of around 8.91 . The effect size on the left and right sides of the inﬂection point, was 0.803 (95% CI 0.742-0.869, p < 0.001) and 1.421 (95% CI 1.159-1.743, p < 0.001), respectively. No signiﬁcant interactions were observed between HRR and all-cause mortality, except in patients with high lactate (p for interaction > 0.05) . The results of the sensitivity analysis remained stable. Conclusions: There is a U-shaped relationship between HRR and 28-day in-hospital all-cause mortality in critically ill pediatric. With a lower mortality risk at an HRR of 8.91 . * Corresponding author. E-mail: [hwchaodoctor@163.com](hwchaodoctor@163.com) (W. He). [https://doi.org/10.1016/j.jped.2025.101491](https://doi.org/10.1016/j.jped.2025.101491) 0021-7557/© 2025 The Author(s). Published by Elsevier España, S.L.U. on behalf of Sociedade Brasileira de Pediatria. This is an open access article under the CC BY license ([http://creativecommons.org/licenses/by/4.0/](http://creativecommons.org/licenses/by/4.0/)). Introduction © 2025 The Author(s) . Published by Elsevier España, S.L.U. on behalf of Sociedade Brasileira de Pediatria. This is an open access article under the CC BY license ([http://creativecommons.org/](http://creativecommons.org/)[ ](http://creativecommons.org/)[licenses/by/4.0/](licenses/by/4.0/) ) . board granted exemption (Hangzhou, China 2019_IRB_052) [23] as data were anonymized and publicly accessible. Mortality prediction and risk assessment are critical in public health and clinical practice.[1] Despite signiﬁcant reductions in child mortality rates from 1990 to 2019 due to initiatives like

FAQs

What was the main objective of this study?

To investigate the association between the hemoglobin to red blood cell distribution width ratio (HRR) and 28-day all-cause mortality among pediatric patients in the PICU.

How was HRR calculated and when were measurements taken?

HRR was calculated using laboratory tests performed within the first 24 hours after PICU admission.

What mortality pattern did the study find between HRR and all-cause mortality?

The relationship was U-shaped, with a threshold around an HRR of 8.91 and different effect sizes on the left and right sides of the inflection point.

Sep 30, 2026

Uploaded by Finn