Re-evaluation of established risk scores by measurement of nucleated red blood cells in blood of surgical intensive care patients

Comparison Evaluation of Automated Nucleated Red Blood Cell Enumeration by Sysmex XN 1000 in Comparison With Microscopic Reference in Children Under 1 Year

BACKGROUND

In newborns, elevated nucleated red blood cell (NRBC) levels can be associated with enhanced erythropoietic stress and might be predictive for adverse outcome. Also, the presence of NRBC in peripheral blood might lead to erroneous enumeration results of white blood cells in automated hematology analyzers. We aimed to assess the comparability of the Sysmex XN 1000 to manual slide reviews and correlation of NRBC with inflammation markers.

METHODS

Specimens of 3397 children under 1 year were compared by automated and microscopic NRBC enumeration. Additionally, potential correlations between NRBC and age and inflammation markers were examined.

RESULTS

Overall, there was good correlation (r = 0.97) between automated (range: 0%-3883%) and microscopic enumeration (range: 0%-3694%) of NRBC with high comparability up to a NRBC value of 200% and an increase in the variation between the two methods with increasing NRBC numbers. When 94 samples with ≤ 200% NRBC and ≥ 30% divergence between methods were separately reanalyzed with respect to overlapping cell populations in their scattergrams, Sysmex would have generated unrecognized incorrect automated results in 47 samples, corresponding to 1.4% of total study samples. NRBC counts were negatively correlated to age, but not to inflammation markers.

CONCLUSION

Sysmex XN 1000 is highly precise in the enumeration of NRBC in children under 1 year up to counts of 200% and might replace time-intense manual counting in routine diagnostics. In the setting of neonatal and intensive care diagnostics, microscopic control and supervision of scattergrams are highly recommended for any automated NRBC enumeration processes.

Peripheral Nucleated Red Blood Cells and Mortality in Critically Ill Children

The present retrospective cohort study examines whether there is an association between circulating nucleated red blood cells (nRBCs) and mortality in critically ill children. nRBCs are erythropoietic progenitor cells not found in peripheral blood of healthy adults and children beyond the neonatal period. The presence of circulating nRBCs is associated with poor prognosis in adults and neonates, though little is known about their significance in children. Admissions to both the general and cardiac pediatric intensive care unit at the Stollery Children's Hospital in Edmonton, Alberta between January 1, 2015 and December 31, 2017 were examined, and logistic regression was performed to ascertain the association between the peak absolute nRBC counts and in-hospital mortality in critically ill children. A total of 2065 admissions were included. The number of admissions with detectable nRBCs was 386 (prevalence: 13.9%), and the number of deaths was 93 (mortality: 4.5%). A statistically significant association was found between the absolute value of nRBC peak and intensive care unit mortality (odds ratio=1.37; 95% confidence interval: 1.13-1.67; P=0.002) as well as hospital mortality (odds ratio=1.38; 95% confidence interval: 1.12-1.70; P=0.003) independent of the Pediatric Index of Mortality 3 score (PIM3). This result warrants more attention to nRBC values and their potential clinical use.

Improvement of mortality prediction accuracy in critically ill patients through combination of SOFA and APACHE II score with markers of stress haematopoiesis

INTRODUCTION

In critically ill patients nucleated red blood cells (NRBC) and immature granulocytes (IG) appear in the peripheral blood as the consequence of stress haematopoesis. The aim of this retrospective study was to evaluate the diagnostic value of NRBC and IG and to propose a model of improved mortality prediction including these parameters in the assessment of critically ill patients.

METHODS

The study included 338 critically ill adult patients hospitalized at Department of Anaesthesiology and Intensive Medicine, Louis Pasteur University Hospital in Kosice. As NRBC positive patients were considered patients with peripheral NRBC > 0.01 × 10⁹ /L and IG positivity as >0.03 × 10⁹ /L. Apache II index was calculated 24 hours after admission and Systemic Organ Failure Assessment (SOFA) on the day with the worst clinical condition.

RESULTS

NRBC positivity was found in 27.6% of patients. The mortality of NRBC positive patients was 48.38%, significantly higher than 23.7% of NRBC negative patients. IG positivity was 79.0% and their mortality was also higher as compared with that of IG negative patients (69.3% vs 33.8%). Three regression models predicting mortality including stress haematopoiesis markers, APACHE II, SOFA scores and age had sufficient level of sensitivity and specificity.

CONCLUSION

The presence of NRBC in the peripheral blood and the IG increase are available early risk predictors of mortality in critically ill patients. Regression models designed by combination of SOFA, APACHE II, and the new haematological parameters increase the accuracy and effectivity of diagnostic process in predicting prognosis and risk of mortality with high sensitivity and specificity.

Emergence role of nucleated red blood cells in molecular response evaluation for chronic myeloid leukemia

Purpose

To investigate and evaluate the role of nucleated red blood cells (NRBCs) and other markers in predicting remission failure in chronic myeloid leukemia (CML) patients treated with imatinib.

Methods

Seventy-one CML patients with BCR-ABL(+) in bone marrow cells were selected for this study. Molecular response evaluations were done every three months according to the recommendations of European LeukemiaNet (ELN). Patients were defined as remission failure if BCR-ABL transcripts >10% after 6 months (T6), >1% after 12 months (T12), and >0.1% after 18 (T18) months of treatment. The logistic regression was used to determine the optimal cut-off point of each marker and test the association of marker level with remission failure.

Results

The median NRBC, white blood cells, blast cells, basophils, and platelets were declined parallel with the decreases of BCR-ABL transcripts in bone marrow cells after 6 months of treatment (P<0.001). In addition, NRBC was almost not found in the blood of patients who archived good response at T6, T12, and T18 time-points. Interestingly, patients with a high level of NRBC (cut-off: 0.003×10⁹/L) have higher BCR-ABL transcripts compared to others. The elevated NRBC at T6 (OR=6.49, P=0.042), T12 (OR=6.73, P=0.007), and T18 (OR=5.96, P=0.009) time-points was identified as an independent factor for the remission failure.

Conclusion

The results of this study showed that a high number of NRBC in peripheral blood of CML patients is associated with higher BCR-ABL transcripts in bone marrow cells. The elevated NRBC might serve as an independent marker for molecular remission failure in CML.

Nucleated red blood cells, critical illness survivors and postdischarge outcomes: a cohort study

Background

Little is known about risk factors associated with out-of-hospital outcomes in survivors of critical illness. We hypothesized that the presence of nucleated red blood cells in patients who survived critical care would be associated with adverse outcomes following hospital discharge.

Methods

We performed a two-center observational cohort study of patients treated in medical and surgical intensive care units in Boston, Massachusetts. All data were obtained from the Research Patient Data Registry at Partners HealthCare. We studied 2878 patients, age ≥ 18 years, who received critical care between 2011 and 2015 and survived hospitalization. The exposure of interest was nucleated red blood cells occurring from 2 days prior to 7 days after critical care initiation. The primary outcome was mortality in the 90 days following hospital discharge. Secondary outcome was unplanned 30-day hospital readmission. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both nucleated red blood cells and outcome. Adjustment included age, race (white versus nonwhite), gender, Deyo–Charlson Index, patient type (medical versus surgical), sepsis and acute organ failure.

Results

In patients who received critical care and survived hospitalization, the absolute risk of 90-day postdischarge mortality was 5.9%, 11.7%, 15.8% and 21.9% in patients with 0/μl, 1–100/μl, 101–200/μl and more than 200/μl nucleated red blood cells respectively. Nucleated red blood cells were a robust predictor of postdischarge mortality and remained so following multivariable adjustment. The fully adjusted odds of 90-day postdischarge mortality in patients with 1–100/μl, 101–200/μl and more than 200/μl nucleated red blood cells were 1.77 (95% CI, 1.23–2.54), 2.51 (95% CI, 1.36–4.62) and 3.72 (95% CI, 2.16–6.39) respectively, relative to patients without nucleated red blood cells. Further, the presence of nucleated red blood cells is a significant predictor of the odds of unplanned 30-day hospital readmission.

Conclusion

In critically ill patients who survive hospitalization, the presence of nucleated red blood cells is a robust predictor of postdischarge mortality and unplanned hospital readmission.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1724-z) contains supplementary material, which is available to authorized users.

Nucleated red blood cells are associated with a higher mortality rate in patients with surgical sepsis

BACKGROUND

Nucleated red blood cells (NRBCs) are present in certain non-oncologic disease states and are associated with a poor prognosis. The purpose of this study was to evaluate NRBCs as an early prognostic marker for death in patients with surgical sepsis.

METHODS

Retrospective evaluation of data collected prospectively from 275 patients from our Investigational Review Board-approved surgical sepsis database over a 27-mo period. The NRBC values were correlated with patient outcomes. The χ(2) test was used for testing of categorical variables and the Mann-Whitney U was used for testing of continuous variables. The level of significance was set at 0.05.

RESULTS

At sepsis recognition, 48 patients (17.5%) were NRBC-positive. The mortality rate was greater in patients who were NRBC positive while in the intensive care unit (ICU); (27% vs. 12%; p=0.007) and during the hospital stay (35.4% vs. 15%; p=0.001). When NRBC-values at all time points are considered, 116 patients (42.2%) were NRBC-positive. The mortality rate was greater in patients who were NRBC-positive in both the ICU (23.3% vs. 8.2%; p<0.001) and during the hospital stay (31% vs. 9.4%; p<0.001). In-hospital and ICU mortality rates increased with increasing NRBC-concentration. For the 153 patients with severe sepsis, NRBC positivity at any time was associated with a higher ICU mortality rate (20% vs. 3.2%; p=0.001). Significant mortality differences did not occur between NRBC-positive and NRBC-negative patients with sepsis (n=48) or septic shock (n=74).

CONCLUSIONS

Surgical sepsis patients with detectable NRBCs are at higher risk of ICU and in-hospital death than those with non-detectable NRBCs. The mortality difference is underscored in surgical patients with severe sepsis. This study suggests NRBCs may be a biomarker of outcomes in patients with surgical sepsis.

Getting back to zero with nucleated red blood cells: following trends is not necessarily a bad thing

BACKGROUND

The presence of nucleated red blood cells (NRBCs) has been identified as a poor prognostic indicator. We investigated the relationship of NRBC trends in patients with and without trauma.

METHODS

We retrospectively reviewed surgical intensive care unit admissions over 4 years, categorizing trauma and nontrauma patients and subdividing them into 3 groups: group A, all-zero NRBC; group B, positive NRBC value returning to zero; and group C, positive NRBC value that did not return to zero. We analyzed all groups for outcomes of length of stay and mortality.

RESULTS

Group A was the largest and had the shortest length of stay and least mortality. Group C had the highest mortality rate. No statistical difference was observed with mortality.

CONCLUSIONS

Any positive NRBC was associated with poor outcome, and increasing NRBC was associated with increasing mortality. Trends in NRBC values showed that returning to zero was protective.

Peripheral nucleated red blood cells as a prognostic indicator in heatstroke in dogs

BACKGROUND

Heatstroke in dogs is often fatal and is associated with a high prevalence of secondary complications. Peripheral nucleated red blood cells (NRBC) occur in dogs with heatstroke, but their association with complications and the outcome is unclear.

HYPOTHESIS

Peripheral NRBC are common in dogs with heatstroke and have prognostic significance.

ANIMALS

Forty client-owned dogs with naturally occurring heatstroke.

METHODS

Prospective, observational study. Dogs were followed from presentation to discharge or death. Serum biochemistry and coagulation tests were performed at presentation. CBC and evaluation of peripheral blood smears were performed at presentation and every 12 hours. The relative and the absolute NRBC numbers were calculated.

RESULTS

Presence of NRBC was observed in 36/40 (90%) of the dogs at presentation. Median relative and absolute NRBC were 24 cells/100 leukocytes (range 0-124) and 1.48 x 10(3)/microL (range 0.0-19.6 x 10(3)/microL), respectively. Both were significantly higher in nonsurvivors (22) versus survivors (18) and in dogs with secondary renal failure and DIC versus those without these complications. Receiver operator curve analysis of relative NRBC at presentation as a predictor of death had an area under curve of 0.92. A cut-off point of 18 NRBC/100 leukocytes corresponded to a sensitivity and specificity of 91 and 88% for death.

CONCLUSIONS AND CLINICAL IMPORTANCE

Relative and absolute numbers of peripheral NRBC are clinically useful, correlate with the secondary complications, and are sensitive and specific markers of death in dogs with heatstroke, although they should never be used as a sole prognostic indicator nor should they replace clinical assessment.