Augmentation of the amplitude of electrocardiographic QRS complexes immediately after hemodialysis: a study of 26 hemodialysis sessions of a single patient, aided by measurements of resistance, reactance, and impedance

doi:10.1016/S0022-0736(03)00050-5

Journal of Electrocardiology

Volume 36, Issue 3, July 2003, Pages 263-271

https://doi.org/10.1016/S0022-0736(03)00050-5 Get rights and content

Abstract

An increase in the amplitude of electrocardiogram QRS complexes (↑ QRS) with hemodialysis (HD) has been invariably documented, but the relationship with weight loss has varied, and other parameters (ie, hemoglobin, body electrical properties), which could be determinants of ↑ QRS, have not all been evaluated in the same patients. We investigated a patient immediately before and after 26 sessions of HD with measurements of a host of variables. Statistically significant correlations were found only between weight loss and net fluid removed (r = .72, P = .0005), and percentage change in the sums of QRS complexes of all 12-electrocardiogram leads and weight lost during HD (r = .41, P = .038). HD imparts a reproducible ↑ QRS, but variation in all the other intercorrelations can be attributed to the complexity of the procedure and its variable impact on many body parameters.

Section snippets

Materials and methods

The database was comprised of a series of 26 HD performed in a 36-year-old woman with a history of long standing hypertension, kidney transplantation for end-stage renal failure in 1991 with subsequent rejection of the transplanted organ who had been maintained on HD thrice a week. In 2001, she was admitted with dyspnea, poorly controlled hypertension, peripheral edema, ascites, and atypical angina. Her medications included clonidine, nifedipine, furosemide, CaCo3, and folic acid. Physical

Results

Data are shown in Table 1. The patient lost a mean of ∼6 lbs (∼5%) of her weight during the 26 sessions of HD. Weight loss correlated well with net fluid removed (r = .72, P = .0005). After HD, a mean increase of 25% in ΣQRS (Fig. 1) and ∼20% in H/H, R, and Z, and a 55% increase in Ro were documented. All these changes were statistically significant with a P = .0005. Other modest but statistically significant changes noted as a result of HD were a decrease in sitting diastolic blood pressure,

Discussion

The main findings of this study are that after HD: 1) the amplitude of the QRS complexes increases; 2) there are concomitant and equal in magnitude rises in H/H, and body R, Z, larger increase in Ro, and modest changes in some other variables noted in Table 1; 3) there is a fair correlation between weight loss and ↑ QRS; and 4) There is no correlation between any other pair of the variables included in Table 1.

The phenomenon of ↑ QRS which was repeatedly shown in all 26 HD sessions in our

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Presentamos una nueva edición de la Guía de Centros de Hemodiálisis. Se enmarca en el programa de actualización de las Guías Clínicas de la Sociedad Española de Nefrología. Es un documento de consenso en el que han colaborado nefrólogos con amplia experiencia en diálisis y expertos de la enfermería nefrológica. La Guía ha sido corregida por un grupo de evaluadores externos. Se ha informado y se ha tomado en consideración la opinión de los enfermos a través de la Asociación de Enfermos Renales (ALCER). Esta Guía incluye en sus diez capítulos aspectos arquitectónicos, logísticos y organizativos. Hace especial énfasis en las necesidades de recursos humanos y su cualificación. Revisa las modalidades actuales de hemodiálisis, su dosificación y adecuación y la monitorización y seguimiento intra e interdiálisis. La hemodiálisis es una de las formas de tratamiento renal sustitutivo, por lo que menciona la necesidad de la inclusión en lista de espera para trasplante y la relación con las unidades de diálisis peritoneal. La calidad de vida del paciente en hemodiálisis comprende la necesidad de relacionarse y viajar por lo que se revisa y estandariza la atención de los pacientes transeúntes. La gestión de calidad es una herramienta necesaria actualmente para lograr la mejora continua de cualquier procedimiento como la hemodiálisis. Esta Guía pretende ser una ayuda para el buen funcionamiento de las Unidades de Diálisis, para los responsables de las mismas, así como para los gestores sanitarios.
Challenges of ECG monitoring and ECG interpretation in dialysis units
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Patients on hemodialysis (HD) suffer from high cardiovascular morbidity and mortality due to high rates of coronary artery disease and arrhythmias. Electrocardiography (ECG) is often performed in the dialysis units as part of routine clinical assessment. However, fluid and electrolyte changes have been shown to affect all ECG morphologies and intervals. ECG interpretation thus depends on the time of the recording in relation to the HD session. In addition, arrhythmias during HD are common, and dialysis-related ECG artifacts mimicking arrhythmias have been reported. Studies using advanced ECG analyses have examined the impact of the HD procedure on selected repolarization descriptors and heart rate variability indices. Despite the challenges related to the impact of the fluctuant fluid and electrolyte status on conventional and advanced ECG parameters, further research in ECG monitoring during dialysis has the potential to provide clinically meaningful and practically useful information for diagnostic and risk stratification purposes.
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Citation Excerpt :
The dynamic appearance/disappearance of SAECG detected “late potentials” in hemodialysis patients therefore likely reflects functional variations in ventricular conduction due to electrolyte changes in the setting of existing myocardial fibrosis and/or scar [29]. Dynamic changes in the presence of late potentials might also be related to changes in QRS complex amplitude and duration associated with hemodialysis and fluid removal [30,31]. Despite the high frequency of abnormal SAECGs in hemodialysis patients, there are no currently available data supporting an association between SAECG abnormalities and total mortality, cardiovascular mortality, or SCD in this population [22,26].
Patients with end stage renal disease (ESRD) on hemodialysis experience a high incidence of cardiovascular mortality, and sudden cardiac death (SCD) accounts for approximately 25% of all deaths in this patient population. Despite this high risk of SCD, many non-invasive SCD risk stratification tools that are frequently applied to other patient populations (such as those with prior myocardial infarction and reduced left ventricular systolic function) may be less useful markers of increased SCD risk in ESRD. Improved SCD risk stratification tools for use specifically in patients on hemodialysis are therefore necessary to optimally target use of primary prevention interventions aimed at decreasing SCD incidence. Electrocardiography is an effective, non-invasive SCD risk stratification tool in hemodialysis patients. This article reviews data supporting the association between various ECG parameters (QT interval, spatial QRS-T angle, signal averaged ECG, heart rate variability, and T-wave alternans) and mortality/SCD in the dialysis population. Despite the association between abnormal ECG parameters and SCD, it remains unclear if these abnormal parameters (such as prolonged QT interval) are mechanistically related to SCD and/or ventricular arrhythmias, or if they are simply markers for more severe cardiac disease, such as left ventricular hypertrophy, that may independently predispose to SCD. Current obstacles that impair widespread implementation of ECG risk stratification in the hemodialysis population are also discussed.
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The ubiquitous smart phone/device technology (SPT) has enabled the safe acquisition/transmission (A/T) of clinical and laboratory patient data, including the electrocardiogram (ECG). SPT-based A/T of the ECG has been found useful in the detection of atrial fibrillation, in monitoring of the QTc interval, in patients undergoing antiarrhythmic drug loading, and in management of patients with acute ST-elevation myocardial infarction. Previous work has shown a relationship between changes in the voltage of the ECG QRS complexes, with perturbations in the edematous state of various etiologies, including heart failure (HF). It is proposed herein to employ serially SPT-based 3-lead ECG A/T for the monitoring and management of patients with HF in their ambient environment. The proposed method will enable patients with HF to acquire/transmit their 3-lead ECG to the caring HF team, using only their smart phone and it takes into consideration the advanced degrees of physical incapacitation and age-related infirmities inherent to the HF population.
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Citation Excerpt :
Secondly, we proposed a significant value of aVR QRS amplitude incline with a cut off value (≥ 0.5 mm) to predict a considerable weight loss (> 5 kg) which is an important clinical surrogate of clinical improvement and that is easy to observe at bedside, clinics or emergency room. The reason of aVR's sole predictive power of recovery amongst the other limb leads was consistent with previous reports [6,18,24,25] and its ability to reflect the conduction characteristics of the heart as a whole together with all interacting compartments. NT-proBNP measurements were outweighed by aVR in predicting the improvement and this finding might be attributed to relatively longer times needed for a change in a hormone level secreted by the structural and functional changes in the geometry of ventricles in contrast to prompt changes in conductivity with diminishing edema in human tissues [8,16,18,25].
We aimed to investigate the correlation between ECG QRS voltage changes, N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and clinical improvement in decompensated heart failure (DHF).
DHF patients (n = 56) with a mean age of 67.5 ± 12.6 years showed limb QRS amplitude increase and NT-proBNP level decrease with clinical improvement (p < 0.001). Significant correlation was found between percent changes (Δ%) in body weight and Δ% in QRS voltages of aVR, aVF, DII, ΣQRSI + II and ΣQRS (all limb-leads) (r = − 0.40; r = − 0.35; r = − 0.32; r = − 0.30; r = − 0.30 respectively, p < 0.05). No correlation was found between Δ% in NT-proBNP and body weight (r = − 0.23, p = 0.09). Δ% NT-proBNP was correlated with Δ% QRS voltage only in aVR (r = − 0.312, p = 0.019). In ROC analysis, ≥ 0.5 mm increase in aVR QRS voltage was found to predict ≥ 5 kg weight loss with a sensitivity of 74% and specificity of 62% (p = 0.013, AUC: 0.699).
Increase in QRS voltages especially in aVR was found to be more sensitive than NT-proBNP to predict clinical improvement in DHF.

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Augmentation of the amplitude of electrocardiographic QRS complexes immediately after hemodialysis: a study of 26 hemodialysis sessions of a single patient, aided by measurements of resistance, reactance, and impedance

Abstract

Section snippets

Materials and methods

Results

Discussion

Am Heart J

J Electrocardiol

Int J Cardiol

Am J Cardiol

J Electrocardiol

Am Heart J

Am J Cardiol

Am Heart J

Am Heart J

Am J Cardiol

J Electrocardiol

Am Heart J

Anasarca-mediated attenuation of the amplitude of ECG complexesA description of a heretofore unrecognized phenomenon

J Am Coll Cardiol

Electrocardiographic changes following dialysis

Nephron

Effects of dialysate sodium concentration on the appearance of ischemic EKG pattern

Nephron

Effects of hemodialysis on body surface maps in patients with chronic renal failure

Nephron

QRS amplitude and volume changes during hemodialysis

Am J Nephrol

Bioimpedance analysis (BIA) in hemodialysistechnical aspects

Inter J Artiff Org

Effect of aging on the body composition of dialyzed subjectsComparison with normal subjects

ASAIO J

Each of anthropometry, bioelectrical impedance analysis and dual-energy X- Ray absorptiometry methods can be used to assess lean body mass in hemodialysis patients

Nephron