RELATIONSHIP BETWEEN ELECTROCARDIOGRAPHY AND ELECTROLYTES BEFORE AND AFTER DIALYSIS IN HEMODIALYSIS PATIENTS

Abstract

Background: Cardiovascular events are the most important cause of mortality in hemodialysis patients. Rapid volume changes and electrolyte shifts during dialysis lead to arrhythmias. Objective: We aimed to determine whether there is a relationship between electrocardiographic (ECG) wave and interval changes and electrolyte levels before and after hemodialysis in dialysis patients. Materials and Method: A total of 112 patients undergoing hemodialysis three times a week for four hours for more than six months were included in the study. Before and after hemodialysis, 12-lead ECG, weight, arterial blood pressure, hemogram, biochemistry, and demographic data were recorded. Waves and intervals were calculated from the 12-lead ECG taken before and immediately after dialysis, and the relationship with serum electrolyte levels was evaluated. P<.05 was considered significant. Results: Among the patients, 51.8% were female, and the mean age was 49.83(±18.69) years. Post-dialysis RR interval correlated negatively with phosphorus (p=.007) and negatively with uric acid (p=.013). Pre-QTc correlated negatively (p=.008) moderately with uric acid and negatively (p=.016) moderately with sodium. In linear regression analysis, phosphorus (p=.007) and uric acid (p=.013) were significant on post-RR, uric acid (p=.008) was significant on pre-QTc, sodium (p=.016) and calcium (p=.027) were significant on post-QTc. Conclusion: The negative correlation between post-dialysis RR interval and phosphorus and uric acid, between pre-dialysis QTc and uric acid, and between post-dialysis QTc and sodium makes ECG interpretation and arrhythmia risk assessment difficult as a result of volume and electrolyte shifts.

Keywords

• : Hemodialysis
• electrocardiography
• electrolytes

Supporting Institution

None

Ethical Statement

It was conducted with the decision of Mardin Artuklu University non-invasive clinical research ethics committee dated May-3.2023 and numbered 2023/5-10.

Thanks

I would like to thank the Mardin dialysis team and my teacher, Prof. Dr. Mehmet Fatih Bulucu, for reading my article.

HEMODİYALİZ HASTALARINDA DİYALİZ ÖNCESİ VE SONRASI ELEKTROKARDİYOGRAFİ İLE ELEKTROLİTLER ARASI İLİŞKİ

Abstract

Bacground: Hemodiyaliz hastalarında kardiyovasküler olaylar en önemli mortalite nedenidir. Diyaliz esnasındaki hızlı volüm değişiklikleri ve elektrolit şiftleri aritmilere önderlik eder. Objective: Diyaliz hastalarında hemodiyaliz öncesi ve sonrası elektrokardiyografik (ECG) dalga ve interval değişiklikleri ile elektrolit düzeyleri arasında ilişki olup olmadığını belirlemeyi amaçladık. Metods: Altı aydan uzun süredir haftada üç kez dört saat hemodiyalize giren 112 hasta çalışmaya alındı. Hemodiyaliz öncesi ve sonrası 12-derivasyonlu EKG, kilo, tansiyon arteriyel, hemogram, biyokimya ve demografik verileri kaydedildi. Diyaliz öncesi ve hemen sonrası çekilen 12-derivasyonlu EKG’den dalga ve intervalleri hesaplanarak serum elektrolit düzeyleri ile arasındaki ilişki değerlendirildi. P<.05 anlamlı kabul edildi. Results: Hastaların %51.8 kadın, ortalama yaş 49.83(±18.69) idi. Diyaliz sonrası RR intervalinin, fosfor ile negatif yönde (p=.007), ürik asit ile negatif yönde (p=.013) korelasyonu bulundu. Öncesi QTc ile ürik asit negatif yönde (p=.008) orta derecede, sonrası QTc ile sodyum negatif yönde (p=.016) orta derecede korelasyonu bulundu. Lineer regresyon analizinde sonrası RR üzerinde fosfor (p=.007) ve ürik asit (p=.013) anlamlı, öncesi QTc üzerinde ürik asit (p=.008) anlamlı, sonrası QTc üzerinde sodyum (p=.016) ve kalsiyum (p=.027) anlamlı bulundu. Conclusion: Diyaliz sonrası RR intervali ile fosfor ve ürik asit arasında negatif yönde, öncesi QTc ile ürik asit arasında ve sonrası QTc ile sodyum arasında negatif yönde bulunan korelasyon, volüm ve elektrolit şiftleri sonucu EKG yorumunu ve aritmi risk değerlendirmesini zorlaştırmaktadır.

Keywords

• Hemodialysis
• electrocardiography
• electrolytes

References

1. 1. Herzog CA, Magnum JM, Passman R. Sudden cardiac death and dialysis patients. Semin Dial. 2008; 21(4):300-7.
2. 2. Herzog CA, Asinger RW, Berger AK, et al. Cardiovascular disease in chronic kidney disease. A clinical uptade from kidney disease: Improving global outcomes (KDIGO). Kidney Int 2011; 80(6):572-86.
3. 3. Genovesi S, Boriani G, Covic A, et al. Sudden cardiac death in dialysis patients: different causes and management strategies. Nephrol Dial Transplant. 2021;36(3):396-405.
4. 4. K/DOQI Workgroup. K/DOQI clinical practice guidlines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005; 45:1-153.
5. 5. Matsumoto Y, Mori Y, Kageyama S, et al. Changes in QTc interval in long term hemodialysis patients. PLoS One 2019; 3:14(1).
6. 6. Waks JW, Tereshchenko LG, Parekh RS. Electrocardiographic predictors of mortality and sudden cardiac death in patients with end stage renal disease on hemodialysis J Electrocardiol. 2016; 49(6):848-54.
7. 7. Marano M, D’Amato A, de Luna AB, Baranchuk A. Hemodialysis Affects Interatrial Conduction. Ann Noninvasive Electrocardiol. 2015; 20(3):299-300.
8. 8. Nishi K, Fujimoto S, Hisanaga S, Ogawa O, Kitamura K. Electrocardiographic assessment of incident atrial fibrillation in hemodialysis patients. Ther Apher Dial 2013;17(1):16-23.

9. 9. Yamaguchi S, Hamano T, Oka T, et.al. Electrocardiogram findings at the initiation of hemodialysis and types of subsequent cardiovascular events. Hypertens Res 2021;44(5):571-580.
10. 10. Tsampasian V, Cameron D, Sobhan R, Bazoukis G, Vassiliou SV. Phosphorus Magnetic Resonance Spectroscopy (31P MRS) and Cardiovascular Disease: The Importance of Energy. Medicine (Kaunas) 2023: 15;59(1):174.
11. 11. Jebali H, Ghabi H, Mami I, et al. Evaluation of electrocardiographic findings before and after hemodialysis session. Saudi J Kidney Dis Transpl 2020;31(3):639-646.
12. 12. Poulikakos D, Malik M. Challenges of ECG monitoring and ECG interpretation in dialysis units. Journal of Electrocardiography 2016: 49(6); 855-859.
13. 13. Covic A, Diaconita M, Gusbeth-Tatomir P, et al. Haemodialysis increases QT(c) interval but not QT(c) dispersion in ESRD patients without manifest cardiac disease. Nephrol Dial Transplant 2002;17(12):2170-7.
14. 14. Octavia D, Suhardjono, Nasution SA, Setiati S. The Clinical Factors’Prediction of Increased Intradialytic QT Dispersion on the Elektrocardiograms of Chronic Hemodialysis Patients. Saudi J Kidney Transpl 2013;24(2):274-280.
15. 15. Korkmaz A, Yıldız A, Kundi H, et al. Can Hemodialysis change QRS axis in patients without cardiovascular disease? Turk Kardiyol Dern Ars 2018:46(4);276-282.
16. 16. Watt J, Fitzpatrick J, Sozio SM, et al. Association of abnormal electrocardiograph metrics with prolonged recovery time in incident hemodialysis patients. BMC Nephrology. 2022;23(1):46.
17. 17. Astan R, Akpınar I, Karan A, et al. The Effect of Hemodialysis on Electrocardiographic Parameters. Ann Noninvazive Electrocardiol 2015;20(3):253-257.
18. 18. Kalantzi K, Gouva C, Letsas KP, et al. The impact of hemodialysis on the dispersion of ventricular repolarization. Pacing Clin Electrophysiol. 2013;36(3):322-7.
19. 19. Ozportakal H, Ozkok A, Alkan O, et al. Hemodialysis-induced repolarization abnormalities on ECG are influenced by serum calcium levels and ultrafiltration volumes. Int Urol Nephrol. 2017: 49(3):509-515.
20. 20. Chen PC, Wu PY, Huang JC, Chen SC, Huang YL. Hyperuricemia is associated with decreased changes in heart rate variability after hemodialysis in non-diabetic patients Oncotarget. 2018;9(9):8738-8745.
21. 21. Zang W, Liang Y, Lv J, Li Y, Sun J. The effects of peritoneal dialysis on QT interval in ESRD patients. BMC Nephrol.2022;23(1):69.
22. 22. Bukhari AH, Palmieri F, Ramirez J, et al. Characterization of T Wave Amplitude, Duration and Morphology Changes During Hemodialysis: Relationship with Serum Electrolyte Levels and Heart Rate. IEEE Trans Biomed Eng 2021;68(8):2467-2478.
23. 23. Tarif N, Yamani H, Bakhsh AJ, et al. Electrocardiography and serum potassium before and after hemodialysis sessions. Saudi J Kidney Dis Transpl. 2008;19(1):47-53.
24. 24. 24. Szewieczek J, Gąsior Z, Duława J, et al. ECG low QRS voltage and wide QRS complex predictive of centenarian 360-day mortality AGE 2016; 38: 44.
25. 25. Wisniowska B, Bielecka ZM, Polak S. How circadian variability of the heart rate and plasma electrolytes concentration influence the cardiac electrophysiology – model-based case study. J Pharmacokinet Pharmacodyn 2021:48:387–399.