The Potential of Electrocardiography for Cardiac Risk Prediction in Chronic and End-stage Kidney Disease

Sofia Skampardoni; Dimitrios Poulikakos; Marek Malik; Darren Green; Philip A. Kalra


Nephrol Dial Transplant. 2019;34(7):1089-1098. 

In This Article


A number of electrocardiographic parameters have been used as potential risk predictors in advanced renal disease and dialysis with variable results. The use of conventional ECG parameters is severely limited by the influence of fluid and electrolyte shifts on their measurements. Inconsistency and lack of reproducibility make them unreliable as independent biomarkers.

In the case of the PR interval prolongation, in particular the link between abnormal PR and mortality might reflect the mortality risk associated with bradyarrhythmias or atrial fibrillation. In the determination of electrocardiographic LVH, the use of Novacode has shown promising results. Novacode has the advantage of not relying on voltage criteria, but requires computer processing of EGC waveform. Hence, unlike conventional methods such as Sokolow–Lyon, LVH cannot be determined by manual observation.

We elected to omit QTc dispersion from the review in order to keep the presented results more relevant. Previous research has indicated that QT dispersion as a metric is problematic as it has very poor reproducibility and cannot be used consistently for risk stratification. There is also some controversy regarding the meaning of QT dispersion as some previous research has questioned whether it truly represents repolarization heterogeneity.[76,77]

Novel markers, such as the QRS–T angle, have shown promising results in HD cohorts. However, the definitions of abnormal QRS–T angle vary significantly depending on the method of calculation used. Further standardization is therefore required. Moreover, the prognostic value of the QRS–T angle needs to be evaluated in larger prospective studies. In general, there is a paucity of studies assessing electrocardiographic markers as risk prediction tools in PD when compared with HD.

In summary, larger and more comprehensive studies are required, including those assessing the evolution of electrocardiographic changes from CKD to HD and PD and the relation of these changes to cardiac mortality. In addition, every opportunity should be taken to include serial ECG recordings in all larger randomized controlled trials examining cardiovascular and mortality outcomes. Risk stratification models that incorporate echocardiographic, electrocardiographic and laboratory parameters together will likely lead to more sensitive and specific risk prediction. Finally, the serious and potentially treatable bradyarrhythmias being detected by implantable loop recording in dialysis patients would itself justify a more regular and perhaps protocolled use of ECG in these populations.