From the Research
An elevated RDW of 20.2 in a 92-year-old patient with history of anemia and very high ferritin (1400) suggests anemia of chronic disease or inflammation, possibly with iron sequestration. This combination indicates that the patient's red blood cells vary significantly in size (anisocytosis), while the high ferritin likely reflects an inflammatory state rather than iron overload 1. The normal other CBC parameters suggest this is a compensated anemia. The patient should undergo further evaluation including:
- a complete iron panel (transferrin, iron, TIBC)
- inflammatory markers (CRP, ESR)
- possibly hemoglobin electrophoresis to rule out hemoglobinopathies. Underlying chronic conditions such as kidney disease, inflammatory disorders, or occult malignancy should be considered 2, 3. Treatment should target the underlying cause rather than iron supplementation, which could be harmful given the high ferritin. The elevated RDW serves as an early marker of dysregulated erythropoiesis before other CBC parameters become abnormal, making it a valuable diagnostic clue in this elderly patient with complex hematologic findings. It is also important to note that RDW has been shown to be a predictor of mortality in critically ill patients and patients undergoing transcatheter aortic valve implantation, highlighting its prognostic value in various clinical settings 2, 3. However, the most recent and highest quality study 1 suggests that the diagnosis of anemia should be based on a thorough history and physical examination, and a complete blood cell count, and that supplemental tests may include a peripheral blood smear, reticulocyte count, and iron panel. Therefore, further evaluation and treatment should be guided by the most recent and highest quality evidence, taking into account the patient's complex medical history and the potential risks and benefits of different treatment options.