The Red Cell Distribution Width (RDW) Blood Test

Uses, Procedure, and Results

The red cell distribution width (RDW) blood test measures how equal your red blood cells are in size and shape. The RDW test is one of several tests included in a complete blood count (CBC), a standard set of labs done on a blood sample.

A lower RDW means that your red blood cells are all about the same size. If the RDW is higher, the sizes of your red blood cells vary more than what's considered normal. A high RDW may be a sign of anemia or another nutrient deficiency.

This article covers why RDW blood tests are done, how the results are interpreted, and what to expect if you are having a RDW blood test.

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Purpose of the RDW Blood Test

The RDW blood test is commonly performed both for screening healthy individuals and to evaluate a wide range of medical conditions, including anemia.

There are times when healthcare providers may specifically look at the value of RDW:

  • When symptoms of anemia, such as lightheadedness or fatigue, are present
  • To help diagnose the causes of anemia (a wide variation in the size of cells or a high RDW may occur when more than one type of anemia is present)
  • To screen people who have a history of a red blood cell condition such as thalassemia
  • With heart disease (an elevated RDW is a strong predictor for eventual heart failure)
  • To screen for early iron deficiency in pregnant women before anemia occurs
  • To screen for early vitamin B12 and folate deficiency before other signs are noted in the blood
  • To have an idea when further blood tests (peripheral smear) are needed
  • As an adjunct in estimating disease risk (heart disease, cancer, and more) or defining prognosis

RDW results are considered one piece of the diagnostic puzzle. A CBC includes several indices, or measurements, pertaining to your red blood corpuscles (the medical term for cells).

The other red cell indices include:

  • Mean corpuscular volume (MCV): A test that measures the average size of your red blood cells.
  • Mean corpuscular hemoglobin (MCH): A test that measures the amount of hemoglobin that each red blood cell contains. Hemoglobin is the protein in red blood cells that carries oxygen.
  • Mean corpuscular hemoglobin concentration (MCHC): A test that determines the amount of hemoglobin present relative to the size of the red blood cell (hemoglobin concentration).

A CBC also includes indices related to your white blood cells and platelets. RDW test results will be considered alongside other CBC results as a healthcare provider evaluates your situation.

Differentiating Types of Anemia

The results of an RDW blood test are used in combination with other indices to tell one type of anemia from another.

For example, both iron deficiency anemia and thalassemia are usually associated with a low MCV, but the two conditions are treated differently. Checking the RDW can help distinguish between these two types of anemia.

Similarly, megaloblastic anemias (such as vitamin B12 deficiency and folate deficiency) and non-megaloblastic anemias (such as anemia related to liver disease) are both associated with a high MCV (macrocytic anemias), but again are treated differently.

In this case, the megaloblastic anemias usually have a high RDW while non-megaloblastic a low RDW, helping to make the distinction.

RDW can also be very helpful in mixed anemias. For example, a combination of iron deficiency (microcytic anemia) and folate deficiency anemia (macrocytosis) may have a normal MCV (normocytic anemia), but the RDW will be very high.

Other Health Concerns

The RDW can be a very helpful number even if there is no evidence of anemia (if the red blood cell count and hemoglobin levels are normal).

The RDW can predict the overall risk of mortality in people over the age of 45 (people with a high RDW are more likely to die earlier on than those who have a lower RDW).

Many studies have been done in the last several years looking at the predictive value of RDW in a wide range of diseases. Some of these include:

  • Heart disease: RDW appears to be a strong predictor of heart failure in people with heart disease, and also predicts the risk of heart disease developing in people with high blood pressure. A 2014 study found that people with a very high RDW (in the top 5%) were 71% more likely to have a heart attack than those who had a lower RDW. A high RDW may also help predict the risk of heart disease in people who are infected with HIV,
  • Cancer: Studies have looked at the role of RDW in cancer in a few different ways. With several types of cancer (such as blood-related cancers, lung cancer, and colon cancer), a high RDW may signify a poorer prognosis.

From another angle, researchers have looked at the potential for RDW to predict the risk of cancer in people who do not currently have the disease. For example, they found a dose-dependent relationship between high RDW values in men and postmenopausal women and future cancer risk.

For people who are undergoing evaluation for unintentional weight loss, a high RDW increased the chance that the weight loss was due to cancer.

  • Surgery: Studies looking at different types of surgery have found that RDW may predict the risk of complications after surgery, to the point where it was pointed out that RDW is important for orthopedic surgeons.
  • Sleep: A high RDW is linked to some sleep disorders, such as sleep apnea, and is also elevated in those who get too little or too much sleep or do shift work.
  • Diabetes: People who have elevated RDW appear to have a greater risk of developing diabetes.

Research on the role of RDW in evaluating conditions other than blood conditions is quite new, and it's expected that more information will be available to better understand the potential benefits of looking at RDW in the future.

  • Inflammatory/Autoimmune Conditions: An increased RDW has been associated with a number of inflammatory and autoimmune conditions, ranging from lupus to autoimmune thyroiditis.

Risks and Limitations

Since the RDW is part of a simple blood test, there are very few risks. Uncommonly people may experience bleeding at the puncture site, bruising (a hematoma), or infection.

There are limitations in evaluating the RDW such as after a person has had a blood transfusion. RDW may also be referred to as erythrocyte distribution width or RDW-SD (standard deviation test).

If an RDW is drawn after a blood transfusion, it won't accurately reflect the RDW of a person's cells. If a lab uses EDTA anticoagulated blood instead of citrated blood, the reading will be falsely high. Since the RDW-CV is calculated using MCV, an error in MCV will result in an error in the RDW.

Before an RDW Test

There are no special dietary or activity restrictions prior to doing an RDW (CBC). You will need to have your insurance card and it's helpful to provide your healthcare provider with any previous CBC results for comparison.

During the Test

A CBC may be drawn in the hospital as well as many clinics.

Before drawing your blood, a lab technician will clean the area (usually an arm) with antiseptic and apply a tourniquet to make the vein easier to see. She will then insert the needle through your skin and into the vein.

While the needle is inserted you may feel a sharp (but short) sting, and some people may experience lightheadedness or feel faint.

After the sample is removed, the needle is removed and pressure applied to the puncture wound. A dressing is then applied to keep the area clean and reduce any bleeding.

After the Test

As soon as your blood is drawn, you will be able to return home. Potential side effects to be aware of include:

  • Bleeding: Sometimes the area where your blood was drawn will continue to bleed, though this is most common for those who are on blood thinners or have a bleeding disorder. Most often this can be resolved with applying pressure, but if bleeding persists you should contact your healthcare provider.
  • Hematoma: Uncommonly, a large bruise may develop where your blood was drawn. This, again, is more common for those who are taking blood thinners such as anti-platelet medications.
  • Infection: There is a very small risk that an infection could develop as a result of bacteria on the skin being introduced into the body during the blood draw. If you notice redness, pain, or warmth in the area, contact your healthcare provider.

If your clinic has a lab associated with it, most often you will receive your results shortly after they are completed. In some cases, the blood sample will be sent out to a lab and your healthcare provider will call with results when they are available.

Interpreting RDW Test Results

RDW results appear on a CBC report alongside all of the other indices. The combination of results is usually used rather than the RDW alone.

Normal red blood cells average between 6 and 8 micrometers in diameter. RDW results are given as a percentage. The normal range for RDW is roughly 11.8% to 15.6%, and the number often increases with age. Reference (normal) ranges for RDW can vary somewhat by the laboratory doing the test, however.

Here's a sense of the possible reasons why your RDW may be low, high, or normal.

Low RDW

Having a low RDW is normal and ideal. It means that your red blood cells are all uniform in size and shape. A low RDW is not associated with any blood disorder.

High RDW

A few types of anemia associated with an elevated RDW include:

  • Iron deficiency anemia including early deficiency
  • Vitamin B12 and folate deficiency
  • Mixed anemias
  • Sickle cell disease
  • Myelofibrosis
  • Cold agglutinin disease

Normal RDW

Even if your CBC results reveal a normal RDW, you can still have anemia. In this case, your healthcare provider will consider other values on your CDC to determine the type of anemia present.

Examples of anemias in which RDW is most often normal include:

  • Thalassemia (some types)
  • Anemia of chronic disease
  • Liver disease
  • Alcohol abuse anemia
  • Aplastic anemia

RDW + Other CBC Results

RDW results will be considered in the context of additional indices you'll find on your CDC report. In addition to the aforementioned MCV, MCH, and MCHC, these include:

The MCV is of particular interest, as certain RDW and MCV result pairings are indicative of certain diagnoses.

The following are examples of conditions that combined RDW and MCV rates may indicate. Note, however, that there are exceptions to these general rules. For example, sometimes anemia of chronic disease is associated with a low MCV, and sometimes iron deficiency anemia will show a normal MCV.

 RDW  MCV Possible Causes
High Low Iron deficiency anemia, sickle cell, beta-thalassemia, or hemoglobin H
High Normal Early iron deficiency anemia, early B12/folate deficiency, blood loss (chronic), or hemolysis
High High Vitamin B12 deficiency, folate deficiency, or immune hemolytic anemia; also a prevalent combination in newborns
Normal Low Anemia of chronic disease, thalassemia, hemoglobin E trait
Normal  Normal Blood loss (acute), anemia of kidney disease, some abnormal hemoglobins, or spherocytosis
Normal High Aplastic anemia, liver disease, alcohol abuse, or some medications (e.g., chemotherapy or antivirals)

Other Tests

Variation in red blood cell size may also be noted visually by looking at a peripheral smear for morphology. This test is usually done after a CBC to investigate an abnormality.

In a peripheral blood smear, the blood sample is viewed under the microscope. In addition to being able to visualize differences in size and shape, other findings may include target cells, nucleated red blood cells, fragmented red blood cells (with hemolysis), and more.

Other tests that may be done to help identify anemia include:

  • Reticulocyte Count: The reticulocyte count helps separate anemias into those based on lack of production of red blood cells (normal reticulocyte count) and those in which there is a loss or break down of red blood cells (blood loss or hemolysis) that are usually associated with a high reticulocyte count..
  • Iron Studies: Serum iron and iron-binding capacity and/or serum ferritin can measure iron stores in the body.
  • Vitamin B12: If vitamin B12 deficiency is suspected, a vitamin B12 level will be drawn.
  • Hemoglobin Electrophoresis: This study can find some (but not all) types of thalassemia.
  • Bone Marrow Study: A bone marrow aspiration and/or biopsy may be done to look at the types of cells in the bone marrow and iron stores.

Follow-Up

Follow-up testing if the RDW is abnormal will depend on many factors. Be sure to discuss your results with your healthcare provider and he/she should provide any follow-up.

A Word From Verywell

Red cell distribution width (RDW) is a valuable tool in evaluating the different types of anemia and may have a wide range of uses even when a person's red blood cell count is normal. In addition to the conditions mentioned above, some argue that RDW could be a measure of general well-being.

For now, it's uncertain the value this test will have in many conditions but it's noteworthy that simple tests such as these may provide important information to be heeded.

Frequently Asked Questions

  • What does it mean if your RDW is high?

    A high RDW has been associated with some types of anemia, vitamin B12 and folate deficiency, sickle cell disease, myelofibrosis, and cold agglutinin disease. It has also been linked to certain conditions unrelated to blood, such as sleep apnea and lupus. A high RDW alone cannot diagnose these conditions, however.

  • Do people with anemia bruise easily?

    Some people with anemia may bruise easily. Other symptoms of anemia can include dizziness, headache, heightened thirst, irritability, sore tongue, lower leg cramping during exercise, tiredness, pale skin, and weakness.

2 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Kaiser Permanente. Complete blood count (CBC).

  2. May J, Marques M, Reddy V, Gangaraju R. Three neglected numbers in the CBC: The RDW, MPV, and NRBC count. Cleve Clin J Med. 2019 Mar;86(3):167-172. doi:10.3949/ccjm.86a.18072

Additional Reading

By Lynne Eldridge, MD
 Lynne Eldrige, MD, is a lung cancer physician, patient advocate, and award-winning author of "Avoiding Cancer One Day at a Time."