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QT Dispersion in Patients with End-Stage Renal Failure and During Hemodialysis

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QT Dispersion in Patients with End-Stage Renal Failure and During Hemodialysis J Am Soc Nephrol 10: 1297–1302, 1999 QT Dispersion in Patients with End-Stage Renal Failure and during Hemodialysis Љ ISTVAN´ LORINCZ, JANOS´ MATYUS,´ ZSOLT ZILAHI, CSABA KUN, ZSOLT KARANYI,´ and GYORGY¨ KAKUK 1st Department of Medicine, University Medical School of Debrecen, Hungary. Abstract. Interlead variability of the QT interval in surface ms postdialysis; the difference was not significant. The maxi- electrocardiogram (ECG), i.e., QT dispersion, reflects regional mal QT interval changed significantly from 449 Ϯ 43 to 469 Ϯ differences in ventricular recovery time, and it has been linked 41 ms (P Ͻ 0.01). The corrected maximal QT interval in- to the occurrence of malignant arrhythmias in different cardiac creased significantly from 482 Ϯ 42 to 519 Ϯ 33 ms (P Ͻ diseases. The purpose of the study was to assess the effect of 0.01). The QT dispersion changed from 56 Ϯ 15 to 85 Ϯ 12 ms hemodialysis on QT and corrected QT (QTc) interval and (P Ͻ 0.001) and the corrected QT interval dispersion from dispersion in chronic hemodialyzed patients. Data of 34 non- 62 Ϯ 18 to 95 Ϯ 17 ms (P Ͻ 0.001). During hemodialysis, the diabetic patients (male/female ϭ 21/13; mean age, 54 Ϯ 15 yr) serum potassium and phosphate levels decreased from 5.5 Ϯ on chronic hemodialysis were studied. Polysulfone capillaries 0.8 to 3.9 Ϯ 0.5 (mM) and from 2.3 Ϯ 0.5 to 1.6 Ϯ 0.4 (mM), and bicarbonate dialysate containing (in mEq/L) 135 Naϩ, 2.0 respectively, whereas calcium increased from 2.2 Ϯ 0.23 to Kϩ, 1.5 Ca2ϩ, and 1.0 Mg2ϩ were used. Simultaneous 12-lead 2.5 Ϯ 0.22 (mM). It is concluded that hemodialysis increases ECG were recorded before and after hemodialysis in a standard the QT and QTc interval and QT and QTc dispersion in setting. The QT intervals for each lead were measured manu- patients with end-stage renal failure. Thus, it may be stated that ally on enlarged (ϫ3) ECG by one observer using cali- the nonhomogeneity of regional ventricular repolarization in- pers. Each QT interval was corrected for patient heart creases during hemodialysis. Measurement of QT and QTc rate: QTc ϭ QT/͌RR (in milliseconds [ms]). The average dispersion is a simple bedside method that can be used for cycle intervals were 853 Ϯ 152 ms predialysis and 830 Ϯ 173 analyzing ventricular repolarization during hemodialysis. Patients with end-stage renal failure commonly have different in conduction velocity and/or repolarization in the different cardiovascular diseases. Although a decline in cardiovascular parts of the ventricle could provide a substrate for tachyar- death has recently been observed in the general population, a rhythmias (8,9). Experimental data have demonstrated a strong similar trend has not been seen in dialysis patients (1,2). link between the vulnerability of the ventricular myocardium According to a number of recent reports, it is known that half and increased temporal dispersion of refractoriness (10). The of the patients receiving chronic hemodialysis therapy die of pathogenic role of increased ventricular repolarization nonho- cardiovascular disease. The main causes are congestive heart mogeneity was confirmed by clinical and experimental studies failure, coronary artery disease, and sudden death as a result of (10,11). The exact spatial dispersion of ventricular myocar- hyperkalemia or arrhythmia (3–5). Reported rates of sudden dium can be determined by invasive methods such as the death in these patients range from 1.4 to 25% (3,6). measurement of monophasic action potentials of the left and However, hemodialysis patients have a wide variety of elec- right ventricle, but it can also be measured by a noninvasive trocardiographic (ECG) abnormalities and, in certain instances, method like surface mapping. Both methods are time consum- hemodialysis itself seems to be a cause of ECG changes and ing and require special technical devices, which limit their use different kinds of dysrhythmias. Arrhythmias are often ob- in everyday practice (11). served after the start of hemodialysis and last at least 5 h after In everyday clinical practice, different methods of surface dialysis (5–7). ECG are being studied for their ability to predict either the The arrhythmogeneity depends partly on variable factors occurrence of these ventricular arrhythmias or their clinical such as autonomic tone, and partly on abnormalities in ven- relevance (6,11). In the conventional ECG, the prolonged QT tricular anatomical structure and metabolism. Nonhomogeneity interval has been reported to be associated with arrhythmogen- esis in a number of cardiac disorders (12). Recent studies have indicated that interlead variability of the QT interval in surface Received May 19, 1998. Accepted December 15, 1998. 12-lead ECG (i.e., the QT interval dispersion defined as the Preliminary data have been presented previously in a letter (see reference (1)). difference between maximal and minimal QT interval dura- Correspondence to Dr. Istva´n Lorincz,Љ Debrecen, Do´czy u. 24. 4032, Hungary. Phone: 36 52 411 600; Fax: 36 52 414 951; E-mail: [email protected] tion) reflects better the regional differences in ventricular re- 1046-6673/1006-1297 covery time. This QT dispersion has been linked to the occur- Journal of the American Society of Nephrology rence of arrhythmias in patients with congenital long QT Copyright © 1999 by the American Society of Nephrology syndromes or with drug-induced tachycardias, and sudden 1298 Journal of the American Society of Nephrology J Am Soc Nephrol 10: 1297–1302, 1999 death in patients with congestive heart failure, hypertrophic Table 1. Clinical data of patientsa cardiomyopathy, hypertensive heart disease, mitral valve pro- lapse syndrome, etc. (9,11,13–19). Furthermore, there are data No. of patients 34 about the increased risk of intraoperative death in two patients Male 21 with renal and liver transplants who had increased QT disper- Female 13 Ϯ sions (128 ms and 125 ms separately) before surgery (20). Average age (yr) 54 15 (20 to 77) Ϯ Moreover, in patients awaiting cardiac transplantation and who Average duration of chronic HD 24 18 Ϯ had QT dispersion longer than 140 ms, there was a fourfold ( SD, months) Ϯ greater risk of death than in patients with QT dispersion shorter Weight loss during dialysis (L) 1.9 1.3 Ϯ than 140 ms. QT dispersion better predicts the risk of sudden Systolic BP at the beginning of HD 150 26 Ϯ death in patients awaiting heart transplantation than the left ( SD, mmHg) Ϯ ventricular ejection fraction (21). Systolic BP at the end of HD 141 24 Ϯ The purpose of our study was to assess the effect of hemo- ( SD, mmHg) Ϯ dialysis on QT and corrected QT (QTc) interval and QT and Diastolic BP at the beginning of 82 11 Ϯ QTc interval dispersion in patients with end-stage renal failure HD ( SD, mmHg) Ϯ 10 min before (pre-HD) and 10 min after each hemodialysis Diastolic BP at the end of HD 80 11 Ϯ (post-HD). ( SD, mmHg) Cause of end-stage renal failure Materials and Methods glomerulonephritis 18 (53%) Patients tubulointerstitial nephritis 7 (20%) The data of 34 adult patients, consisting of 21 men and 13 women nephrosclerosis 5 (15%) on chronic hemodialysis with a mean age of 54 Ϯ 15 yr (range, 21 to autosomal dominant polycystic 2 (6%) 78), were studied. The causes of chronic renal failure were as follows: kidney disease glomerulonephritis (n ϭ 18), tubulointerstitial nephritis (n ϭ 7), renal tubular acidosis 1 (3%) nephrosclerosis (n ϭ 5), polycystic kidney disease (n ϭ 2), and other unknown origin 1 (3%) (n ϭ 2) (Table 1). Exclusion criteria were: (1) unmeasurable T waves; Cardiac complications (2) atrial fibrillation; (3) bundle branch block; and (4) antiarrhythmic angina pectoris 7 (20%) drugs that lengthen the QT interval. The mean duration of hemodial- old myocardial infarction 2 (6%) Ϯ ysis was 22 19 mo (range, 1 to 77). The dialyses were carried out valvular heart disease 2 (6%) in a standard setting (Fresenius 2008 device; Fresenius Medical Care, cardiomyopathy 4 (12%) Bad Homburg, Germany) with F6 and F8 polysulfone capillaries (Fresenius) for 3.5 to4h2or3times per week. Bicarbonate dialysate sick sinus syndrome 1 (3%) containing (in mM) 135 Naϩ, 2.0 Kϩ, 1.5 Ca2ϩ, and 1.0 Mg2ϩ was supraventricular tachycardia 1 (3%) used. During hemodialysis, no drug therapy was applied, except Medication isotonic NaCl or hypertonic (10%) NaCl infusions and sodium hep- digoxin 4 (12%) arin. The maintenance drug therapy including digitalis, antihyperten- antiarrhythmic medication (beta 8 (24%) sive, antianginal, and beta blocking agents was not changed. The blockers) following laboratory tests were performed before hemodialysis and at other (antihypertensive drugs) 12 (34%) the end of treatment: serum electrolyte Naϩ,Kϩ,Mg2ϩ,Ca2ϩ, phosphate, blood urea nitrogen, and creatinine. Arterial BP and heart a HD, hemodialysis. rate were recorded during the procedure. Intact parathyroid hormone level was determined by RIA (BioRad; normal value 1.2 to 6.8 for each lead were measured manually with calipers by one observer. pmol/L). Different data subgroups were created according to age; The QT interval was measured from the first deflection of the QRS gender; the duration of the hemodialysis program; the presence or complex to the point of T wave offset, defined by the return of the absence of ischemic heart disease; the presence or absence of hyper- terminal T wave to the isoelectric TP baseline. In the presence of U tension; the use or nonuse of beta blocking agents; and the presence wave interrupting the T wave, the terminal portion of the visible T or absence of severe hyperparathyroidism (if the parathyroid hormone wave was extrapolated to the TP baseline to define the point of T [PTH] level was Ͼ40 pmol/L).
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