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Bukhari HA, Sánchez C, Laguna P, Potse M, Pueyo E. Differences in ventricular wall composition may explain inter-patient variability in the ECG response to variations in serum potassium and calcium. Front Physiol 2023; 14:1060919. [PMID: 37885805 PMCID: PMC10598848 DOI: 10.3389/fphys.2023.1060919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 09/18/2023] [Indexed: 10/28/2023] Open
Abstract
Objective: Chronic kidney disease patients have a decreased ability to maintain normal electrolyte concentrations in their blood, which increases the risk for ventricular arrhythmias and sudden cardiac death. Non-invasive monitoring of serum potassium and calcium concentration, [K+] and [Ca2+], can help to prevent arrhythmias in these patients. Electrocardiogram (ECG) markers that significantly correlate with [K+] and [Ca2+] have been proposed, but these relations are highly variable between patients. We hypothesized that inter-individual differences in cell type distribution across the ventricular wall can help to explain this variability. Methods: A population of human heart-torso models were built with different proportions of endocardial, midmyocardial and epicardial cells. Propagation of ventricular electrical activity was described by a reaction-diffusion model, with modified Ten Tusscher-Panfilov dynamics. [K+] and [Ca2+] were varied individually and in combination. Twelve-lead ECGs were simulated and the width, amplitude and morphological variability of T waves and QRS complexes were quantified. Results were compared to measurements from 29 end-stage renal disease (ESRD) patients undergoing hemodialysis (HD). Results: Both simulations and patients data showed that most of the analyzed T wave and QRS complex markers correlated strongly with [K+] (absolute median Pearson correlation coefficients, r, ranging from 0.68 to 0.98) and [Ca2+] (ranging from 0.70 to 0.98). The same sign and similar magnitude of median r was observed in the simulations and the patients. Different cell type distributions in the ventricular wall led to variability in ECG markers that was accentuated at high [K+] and low [Ca2+], in agreement with the larger variability between patients measured at the onset of HD. The simulated ECG variability explained part of the measured inter-patient variability. Conclusion: Changes in ECG markers were similarly related to [K+] and [Ca2+] variations in our models and in the ESRD patients. The high inter-patient ECG variability may be explained by variations in cell type distribution across the ventricular wall, with high sensitivity to variations in the proportion of epicardial cells. Significance: Differences in ventricular wall composition help to explain inter-patient variability in ECG response to [K+] and [Ca2+]. This finding can be used to improve serum electrolyte monitoring in ESRD patients.
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Affiliation(s)
- Hassaan A. Bukhari
- BSICoS Group, I3A Institute, University of Zaragoza, IIS Aragón, Zaragoza, Spain
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
- Carmen Team, Inria Bordeaux—Sud-Ouest, Talence, France
- University of Bordeaux, IMB, UMR 5251, Talence, France
| | - Carlos Sánchez
- BSICoS Group, I3A Institute, University of Zaragoza, IIS Aragón, Zaragoza, Spain
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
| | - Pablo Laguna
- BSICoS Group, I3A Institute, University of Zaragoza, IIS Aragón, Zaragoza, Spain
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
| | - Mark Potse
- Carmen Team, Inria Bordeaux—Sud-Ouest, Talence, France
- University of Bordeaux, IMB, UMR 5251, Talence, France
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
| | - Esther Pueyo
- BSICoS Group, I3A Institute, University of Zaragoza, IIS Aragón, Zaragoza, Spain
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
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Metshein M, Krivošei A, Abdullayev A, Annus P, Märtens O. Non-Standard Electrode Placement Strategies for ECG Signal Acquisition. SENSORS (BASEL, SWITZERLAND) 2022; 22:9351. [PMID: 36502052 PMCID: PMC9740955 DOI: 10.3390/s22239351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Wearable technologies for monitoring cardiovascular parameters, including electrocardiography (ECG) and impedance cardiography (ICG), propose a challenging research subject. The expectancy for wearable devices to be unobtrusive and miniaturized sets a goal to develop smarter devices and better methods for signal acquisition, processing, and decision-making. METHODS In this work, non-standard electrode placement configurations (EPC) on the thoracic area and single arm were experimented for ECG signal acquisition. The locations were selected for joint acquisition of ECG and ICG, targeted to suitability for integrating into wearable devices. The methodology for comparing the detected signals of ECG was developed, presented, and applied to determine the R, S, and T waves and RR interval. An algorithm was proposed to distinguish the R waves in the case of large T waves. RESULTS Results show the feasibility of using non-standard EPCs, manifesting in recognizable signal waveforms with reasonable quality for post-processing. A considerably lower median sensitivity of R wave was verified (27.3%) compared with T wave (49%) and S wave (44.9%) throughout the used data. The proposed algorithm for distinguishing R wave from large T wave shows satisfactory results. CONCLUSIONS The most suitable non-standard locations for ECG monitoring in conjunction with ICG were determined and proposed.
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Kim S, Yun D, Kwon S, Lee SR, Kim K, Kim YC, Kim DK, Oh KH, Joo KW, Lee HC, Jung CW, Kim YS, Han SS. System of integrating biosignals during hemodialysis: the CONTINUAL (Continuous mOnitoriNg viTal sIgN dUring hemodiALysis registry. Kidney Res Clin Pract 2022; 41:363-371. [PMID: 35698753 PMCID: PMC9184839 DOI: 10.23876/j.krcp.21.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/01/2021] [Indexed: 12/04/2022] Open
Abstract
Background Appropriate monitoring of intradialytic biosignals is essential to minimize adverse outcomes because intradialytic hypotension and arrhythmia are associated with cardiovascular risk in hemodialysis patients. However, a continuous monitoring system for intradialytic biosignals has not yet been developed. Methods This study investigated a cloud system that hosted a prospective, open-source registry to monitor and collect intradialytic biosignals, which was named the CONTINUAL (Continuous mOnitoriNg viTal sIgN dUring hemodiALysis) registry. This registry was based on real-time multimodal data acquisition, such as blood pressure, heart rate, electrocardiogram, and photoplethysmogram results. Results We analyzed session information from this system for the initial 8 months, including data for some cases with hemodynamic complications such as intradialytic hypotension and arrhythmia. Conclusion This biosignal registry provides valuable data that can be applied to conduct epidemiological surveys on hemodynamic complications during hemodialysis and develop artificial intelligence models that predict biosignal changes which can improve patient outcomes.
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Affiliation(s)
- Seonmi Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Donghwan Yun
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Soonil Kwon
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kwangsoo Kim
- Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong Chul Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwon Wook Joo
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yon Su Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Seok Han
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Correspondence: Seung Seok Han Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea. E-mail:
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Bukhari HA, Sánchez C, Ruiz JE, Potse M, Laguna P, Pueyo E. Monitoring of Serum Potassium and Calcium Levels in End-Stage Renal Disease Patients by ECG Depolarization Morphology Analysis. SENSORS 2022; 22:s22082951. [PMID: 35458934 PMCID: PMC9027214 DOI: 10.3390/s22082951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/16/2022]
Abstract
Objective: Non-invasive estimation of serum potassium, [K+], and calcium, [Ca2+], can help to prevent life-threatening ventricular arrhythmias in patients with advanced renal disease, but current methods for estimation of electrolyte levels have limitations. We aimed to develop new markers based on the morphology of the QRS complex of the electrocardiogram (ECG). Methods: ECG recordings from 29 patients undergoing hemodialysis (HD) were processed. Mean warped QRS complexes were computed in two-minute windows at the start of an HD session, at the end of each HD hour and 48 h after it. We quantified QRS width, amplitude and the proposed QRS morphology-based markers that were computed by warping techniques. Reference [K+] and [Ca2+] were determined from blood samples acquired at the time points where the markers were estimated. Linear regression models were used to estimate electrolyte levels from the QRS markers individually and in combination with T wave morphology markers. Leave-one-out cross-validation was used to assess the performance of the estimators. Results: All markers, except for QRS width, strongly correlated with [K+] (median Pearson correlation coefficients, r, ranging from 0.81 to 0.87) and with [Ca2+] (r ranging from 0.61 to 0.76). QRS morphology markers showed very low sensitivity to heart rate (HR). Actual and estimated serum electrolyte levels differed, on average, by less than 0.035 mM (relative error of 0.018) for [K+] and 0.010 mM (relative error of 0.004) for [Ca2+] when patient-specific multivariable estimators combining QRS and T wave markers were used. Conclusion: QRS morphological markers allow non-invasive estimation of [K+] and [Ca2+] with low sensitivity to HR. The estimation performance is improved when multivariable models, including T wave markers, are considered. Significance: Markers based on the QRS complex of the ECG could contribute to non-invasive monitoring of serum electrolyte levels and arrhythmia risk prediction in patients with renal disease.
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Affiliation(s)
- Hassaan A. Bukhari
- BSICoS Group, I3A Institute, IIS Aragón, University of Zaragoza, 50018 Zaragoza, Spain; (C.S.); (P.L.); (E.P.)
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain
- Carmen Team, Inria Bordeaux—Sud-Ouest, 33405 Talence, France;
- Université de Bordeaux, IMB, UMR 5251, 33400 Talence, France
- Correspondence:
| | - Carlos Sánchez
- BSICoS Group, I3A Institute, IIS Aragón, University of Zaragoza, 50018 Zaragoza, Spain; (C.S.); (P.L.); (E.P.)
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain
| | - José Esteban Ruiz
- Nephrology Department, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain;
| | - Mark Potse
- Carmen Team, Inria Bordeaux—Sud-Ouest, 33405 Talence, France;
- Université de Bordeaux, IMB, UMR 5251, 33400 Talence, France
| | - Pablo Laguna
- BSICoS Group, I3A Institute, IIS Aragón, University of Zaragoza, 50018 Zaragoza, Spain; (C.S.); (P.L.); (E.P.)
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain
| | - Esther Pueyo
- BSICoS Group, I3A Institute, IIS Aragón, University of Zaragoza, 50018 Zaragoza, Spain; (C.S.); (P.L.); (E.P.)
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain
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Bukhari HA, Sánchez C, Srinivasan S, Palmieri F, Potse M, Laguna P, Pueyo E. Estimation of potassium levels in hemodialysis patients by T wave nonlinear dynamics and morphology markers. Comput Biol Med 2022; 143:105304. [PMID: 35168084 DOI: 10.1016/j.compbiomed.2022.105304] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/01/2022] [Accepted: 02/05/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Noninvasive screening of hypo- and hyperkalemia can prevent fatal arrhythmia in end-stage renal disease (ESRD) patients, but current methods for monitoring of serum potassium (K+) have important limitations. We investigated changes in nonlinear dynamics and morphology of the T wave in the electrocardiogram (ECG) of ESRD patients during hemodialysis (HD), assessing their relationship with K+ and designing a K+ estimator. METHODS ECG recordings from twenty-nine ESRD patients undergoing HD were processed. T waves in 2-min windows were extracted at each hour during an HD session as well as at 48 h after HD start. T wave nonlinear dynamics were characterized by two indices related to the maximum Lyapunov exponent (λt, λwt) and a divergence-related index (η). Morphological variability in the T wave was evaluated by three time warping-based indices (dw, reflecting morphological variability in the time domain, and da and daNL, in the amplitude domain). K+was measured from blood samples extracted during and after HD. Stage-specific and patient-specific K+ estimators were built based on the quantified indices and leave-one-out cross-validation was performed separately for each of the estimators. RESULTS The analyzed indices showed high inter-individual variability in their relationship with K+. Nevertheless, all of them had higher values at the HD start and 48 h after it, corresponding to the highest K+. The indices η and dw were the most strongly correlated with K+ (median Pearson correlation coefficient of 0.78 and 0.83, respectively) and were used in univariable and multivariable linear K+ estimators. Agreement between actual and estimated K+ was confirmed, with averaged errors over patients and time points being 0.000 ± 0.875 mM and 0.046 ± 0.690 mM for stage-specific and patient-specific multivariable K+ estimators, respectively. CONCLUSION ECG descriptors of T wave nonlinear dynamics and morphological variability allow noninvasive monitoring of K+ in ESRD patients. SIGNIFICANCE ECG markers have the potential to be used for hypo- and hyperkalemia screening in ESRD patients.
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Affiliation(s)
- Hassaan A Bukhari
- BSICoS group, I3A Institute, University of Zaragoza, IIS Aragón, Zaragoza, Spain; CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain; Carmen team, Inria Bordeaux - Sud-Ouest, Talence, France; University of Bordeaux, IMB, UMR 5251, Talence, France.
| | - Carlos Sánchez
- BSICoS group, I3A Institute, University of Zaragoza, IIS Aragón, Zaragoza, Spain; CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
| | - Sabarathinam Srinivasan
- BSICoS group, I3A Institute, University of Zaragoza, IIS Aragón, Zaragoza, Spain; CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
| | - Flavio Palmieri
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain; Centre de Recerca en Enginyeria Biomèdica, Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Mark Potse
- Carmen team, Inria Bordeaux - Sud-Ouest, Talence, France; University of Bordeaux, IMB, UMR 5251, Talence, France
| | - Pablo Laguna
- BSICoS group, I3A Institute, University of Zaragoza, IIS Aragón, Zaragoza, Spain; CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
| | - Esther Pueyo
- BSICoS group, I3A Institute, University of Zaragoza, IIS Aragón, Zaragoza, Spain; CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
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Palmieri F, Gomis P, Ferreira D, Pueyo E, Martinez JP, Laguna P, Ramirez J. Weighted Time Warping Improves T-wave Morphology Markers Clinical Significance. IEEE Trans Biomed Eng 2022; 69:2787-2796. [PMID: 35196223 DOI: 10.1109/tbme.2022.3153791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background: T-wave (TW) morphology indices based on time-warping (dw) have shown significant cardiovascular risk stratification value. However, errors in the location of TW boundaries may impact their prognostic power. Our aim was to test the hypothesis that a weighted time-warping function (WF) would reduce the sensitivity of dw to these errors and improve their clinical significance. Methods: The WFs were proportional to (i) the reference TW (T), and (ii) the absolute value of its derivative (D). The index dw was recalculated using these WFs, and its performance was compared to the unweighted control case (C) in four different scenarios: 1) robustness against simulated TW boundaries location errors; 2) ability to retain physiological information in an electrophysiological cardiac model; 3) ability to monitor blood potassium concentration changes ([K+]) in 29 hemodialysis (HD) patients; 4) and the sudden cardiac death (SCD) risk stratification value of the TW morphology restitution (TMR) index, derived from dw, in 651 chronic heart failure (CHF) patients. Results and Discussion: The WFs led to a reduced sensitivity (R) of dw to TW boundary location errors as compared to C (median R=0.19 and 0.22 and 0.35 for T, D and C, respectively). They also preserved the physiological relationship between dw and repolarization dispersion changes at ventricular level. No improvements in [K+] tracking were observed for the HD patients (Pearsons median correlation [r] between [K+] and dw was 0.86r0.90 for T, D and C). In CHF patients, the SCD risk stratification value of TMR was improved by applying T (hazard ratio, HAR, of 2.80), followed by D (HAR=2.32) and C (HAR=2.23). Conclusions and Significance: The proposed WFs, with T showing the best performance, increased the robustness of time-warping based markers against TW location errors preserving their physiological information content and boosting their SCD risk stratification value. Results from this work support the use of T when deriving dw for future clinical applications.
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Palmieri F, Gomis P, Ruiz JE, Ferreira D, Martín-Yebra A, Pueyo E, Martínez JP, Ramírez J, Laguna P. ECG-based monitoring of blood potassium concentration: Periodic versus principal component as lead transformation for biomarker robustness. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Palmieri F, Gomis P, Ruiz JE, Ferreira D, Martín-Yebra A, Pueyo E, Martínez JP, Ramírez J, Laguna P. Nonlinear T-Wave Time Warping-Based Sensing Model for Non-Invasive Personalised Blood Potassium Monitoring in Hemodialysis Patients: A Pilot Study. SENSORS 2021; 21:s21082710. [PMID: 33921468 PMCID: PMC8069025 DOI: 10.3390/s21082710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/16/2021] [Accepted: 03/30/2021] [Indexed: 11/24/2022]
Abstract
Background: End-stage renal disease patients undergoing hemodialysis (ESRD-HD) therapy are highly susceptible to malignant ventricular arrhythmias caused by undetected potassium concentration ([K+]) variations (Δ[K+]) out of normal ranges. Therefore, a reliable method for continuous, noninvasive monitoring of [K+] is crucial. The morphology of the T-wave in the electrocardiogram (ECG) reflects Δ[K+] and two time-warping-based T-wave morphological parameters, dw and its heart-rate corrected version dw,c, have been shown to reliably track Δ[K+] from the ECG. The aim of this study is to derive polynomial models relating dw and dw,c with Δ[K+], and to test their ability to reliably sense and quantify Δ[K+] values. Methods: 48-hour Holter ECGs and [K+] values from six blood samples were collected from 29 ESRD-HD patients. For every patient, dw and dw,c were computed, and linear, quadratic, and cubic fitting models were derived from them. Then, Spearman’s (ρ) and Pearson’s (r) correlation coefficients, and the estimation error (ed) between Δ[K+] and the corresponding model-estimated values (Δ^[K+]) were calculated. Results and Discussions: Nonlinear models were the most suitable for Δ[K+] estimation, rendering higher Pearson’s correlation (median 0.77 ≤r≤ 0.92) and smaller estimation error (median 0.20 ≤ed≤ 0.43) than the linear model (median 0.76 ≤r≤ 0.86 and 0.30 ≤ed≤ 0.40), even if similar Spearman’s ρ were found across models (median 0.77 ≤ρ≤ 0.83). Conclusion: Results support the use of nonlinear T-wave-based models as Δ[K+] sensors in ESRD-HD patients.
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Affiliation(s)
- Flavio Palmieri
- Centre de Recerca en Enginyeria Biomèdica, Universitat Politècnica de Catalunya, 08028 Barcelona, Spain; (F.P.); (P.G.)
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain; (A.M.-Y.); (E.P.); (J.P.M.)
- Laboratorios Rubió, Castellbisbal, 08755 Barcelona, Spain;
| | - Pedro Gomis
- Centre de Recerca en Enginyeria Biomèdica, Universitat Politècnica de Catalunya, 08028 Barcelona, Spain; (F.P.); (P.G.)
- Escuela Superior de Ingeniería, Ciencia y Tecnología, Universidad Internacional de Valencia, 46002 Valencia, Spain
| | - José Esteban Ruiz
- Nephrology Ward, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain;
| | - Dina Ferreira
- Laboratorios Rubió, Castellbisbal, 08755 Barcelona, Spain;
| | - Alba Martín-Yebra
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain; (A.M.-Y.); (E.P.); (J.P.M.)
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, 50018 Zaragoza, Spain
| | - Esther Pueyo
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain; (A.M.-Y.); (E.P.); (J.P.M.)
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, 50018 Zaragoza, Spain
| | - Juan Pablo Martínez
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain; (A.M.-Y.); (E.P.); (J.P.M.)
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, 50018 Zaragoza, Spain
| | - Julia Ramírez
- William Harvey Research Institute, Queen Mary University of London, London E1 4NS, UK;
| | - Pablo Laguna
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain; (A.M.-Y.); (E.P.); (J.P.M.)
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, 50018 Zaragoza, Spain
- Correspondence:
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