The red cell distribution width (RDW) is a parameter that measures variation in red blood cell size

or red blood cell volume. It is a part of a standard complete blood count (CBC), and it is used along

with other RBC indices, especially mean corpuscular volume (MCV) to help determine the causes

of anemia. RDW is elevated in accordance with variation in red cell size (anisocytosis), ie, when

elevated RDW is reported on complete blood count, marked anisocytosis (increased variation in red

cell size) is expected on peripheral blood smear review. Extreme RBC volume variability is visible on

the Wright-stained blood film as variation in diameter and is called anisocytosis. The RDW is based on

the standard deviation of RBC volume and is routinely reported by automated cell counters. The RDW is

determined from the histogram of RBC volumes. Briefly, when the volumes of the RBCs are about the

same, the histogram is narrow. If the volumes are variable (more small cells, more large cells, or both),

the histogram becomes wider. The width of the histogram, the RDW, is reflected statiscally as a

coefficient of variation (CV) or a standard deviation (SD). Most analyzer manufacturers provide a CV and

an SD, and the operator can select which to report. Therefore, the RDW provides information about the

presence and degree of anisocytosis (variation in RBC volume). What is important is increased values

only, not decreased values. If an RDW-CV reference interval is 11.5% to 14.5% and a patient has an

RDW-CV of 20.6%, the patient has a more heterogeneous RBC population with more variation in cell

volume (anisocytosis). If the RDW is elevated, a notation about anisocytosis is expected in the

morphologic evaluation of the blood film. Using the MCV along with the RDW provides the most helpful

information. The RDW is the coefficient of variation of RBC volume expressed as a percentage. It

indicates the variation in RBC volume within the population measured and an increased RDW correlates

with anisocytosis on the peripheral blood film. Automated analyzers calculate the RDW by dividing the

standard deviation of the RBC volume by the MCV and then multiplying by 100 to convert to a

percentage. The RDW can help determine the cause of an anemia when used in conjunction with the

MCV. Each of the three MCV categories mentioned previously (normocytic, microcytic, macrocytic) can

also be subclassified by the RDW as homogenous (normal RDW) or heterogeneous (increased or high

RDW), according to Bessman and colleagues. For example, a decreased MCV with an increased RDW is
suggestive of iron deficiency. This classification is not absolute, however, because there can be an overlap

of RDW values among some of the conditions in each MCV category. The red blood cell distribution

width is elevated in newborns, with a reference interval of 14.2% to 17.8% the first 30 days of life. After

that it gradually decreases and reaches the adult reference interval by 6 months of age.

Elevated RDW helps provide a clue for a diagnosis of early nutritional deficiency such as iron, folate, or

vitamin B12 deficency as it becomes elevated earlier than other red blood cell parameters. It aids in

distinguishing between uncomplicated iron deficiency anemia (elevated RDW, normal to low MCV) and

uncomplicated heterozygous thalassemia (normal RDW, low MCV); however, definitive tests are

required. It can also help distinguish between megaloblastic anemia such as folate or vitamin B12

deficiency anemia (elevated RDW) and other causes of macrocytosis (often normal RDW). RDW can be

used as a guidance for flagging samples that may need manual peripheral blood smear examination, since

elevated RDW may indicate red cell fragmentation, agglutination, or dimorphic red blood cell populations.

Elevated RDW provides a clue for heterogenous red cell size (anisocytosis) and/or the presence of 2 red

cell populations, since other RBC indices (MCV, MCH and MCHC) reflect average values and may not

adequately reflect RBC changes where mixed RBC populations are present, such as dimorphic RBC

populations in sideroblastic anemia or combined iron deficiency anemia (decreased MCV and MCH) and

megaloblastic anemia (increased MCV). Peripheral blood smear review can help confirm the above

findings in these circumstances.

 MEAN CELL VOLUME

Decreased Normal Increased

RDW Normal - or - thalassemia Anemia of chronic Aplastic anemia

trait inflammation Chronic liver

Anemia of chronic Anemia of renal disease

inflammation disease Alcoholism

Hb E disease/trait Acute hemorrhage Chemotherapy

Hereditary

spherocytosis

RDW Increased Iron deficiency Early iron, folate, or Folate or vitamin

Sickle cell-- vitamin B12 B12 deficiency

thalassemia deficiency Myelodysplastic

Mixed deficiency of syndrome

iron + vitamin B12 Cold agglutinin

or folate disease

Sickle cell anemia Chronic liver

Hb SC disease disease

Myelodysplastic Chemotherapy

syndrome

Table 1. Morphologic Classification of Anemia Based on Red Blood Cell Mean Volume (MCV) and Red

Blood Cell Distribution Width (RDW)