DOI: 10.1177/03000605261472029 ISSN: 0300-0605

Red cell distribution width-to-albumin ratio predicts mortality in critically ill patients with gastrointestinal bleeding: A retrospective cohort study with external validation

Lihong Lv, Xuyong Chen, Xiangshu Yuan, Xingyi Yang
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Objective

The red cell distribution width-to-albumin ratio reflects systemic inflammatory burden and nutritional status. However, its prognostic value in critically ill patients with gastrointestinal bleeding has not been well established. This study assessed the association between the red cell distribution width-to-albumin ratio and mortality and developed a multivariable model for early risk stratification and mortality estimation.

Methods

This retrospective cohort study included adult intensive care unit patients with a primary diagnosis of gastrointestinal bleeding from the Medical Information Mart Intensive Care IV database, with external validation performed using the electronic intensive care unit Collaborative Research Database. Covariates for Cox proportional hazards models examining 28-day and 90-day mortality were selected using the least absolute shrinkage and selection operator in combination with clinical judgment. Kaplan–Meier survival analyses, receiver operating characteristic curves, and restricted cubic spline modeling were performed. Predictors identified by the Boruta algorithm were incorporated into a nomogram for early mortality estimation.

Results

A total of 1620 patients were included, with a 28-day mortality of 18.6%. Non-survivors exhibited substantially higher red cell distribution width-to-albumin ratio values. After full adjustment, the red cell distribution width-to-albumin ratio remained significantly associated with 28-day mortality (hazard ratio 1.12, 95% confidence interval 1.07–1.18) and 90-day mortality (hazard ratio 1.14, 95% confidence interval 1.09–1.20; both p  < 0.001). Higher red cell distribution width-to-albumin ratio was associated with markedly reduced survival, and restricted cubic spline modeling showed an approximately linear increase in mortality risk across the red cell distribution width-to-albumin ratio spectrum. The nomogram constructed from key predictors—including the red cell distribution width-to-albumin ratio—demonstrated strong discrimination in internal validation (area under the curve 0.814) and maintained stable performance in external validation (area under the curve 0.826).

Conclusions

The red cell distribution width-to-albumin ratio may serve as a pragmatic early indicator for risk stratification in critically ill patients with gastrointestinal bleeding. The multivariable nomogram incorporating the red cell distribution width-to-albumin ratio may support individualized mortality risk estimation and showed stable performance across independent cohorts.

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