Most Likely ECG Finding: Peaked T Waves
The most likely ECG finding in this patient with ESRD on hemodialysis presenting with fluid overload is peaked T waves (Option A), which indicates hyperkalemia—a life-threatening electrolyte abnormality common in dialysis patients, particularly between dialysis sessions. 1
Clinical Context and Pathophysiology
This patient presents with classic signs of volume overload in ESRD:
- Elevated jugular venous pressure (JVP) is the most reliable sign of volume overload 1
- +3 bilateral lower extremity edema indicates significant fluid retention 1
- Shortness of breath correlates with fluid overload causing pulmonary congestion 2
However, the critical ECG finding relates to hyperkalemia, not just fluid status. Patients with ESRD on hemodialysis are at highest risk for hyperkalemia during the interdialytic period when potassium accumulates without renal excretion 1.
Why Peaked T Waves (Option A)
Hyperkalemia produces characteristic ECG changes in a progressive sequence 1:
- Early finding: Peaked, narrow, symmetric T waves (typically when K+ >5.5-6.0 mEq/L)
- Progressive findings include PR prolongation, loss of P waves, and widening of QRS complex
- Terminal findings include sine wave pattern and cardiac arrest
Peaked T waves are the earliest and most common ECG manifestation of hyperkalemia in dialysis patients, making this the most likely finding in a patient presenting between dialysis sessions with fluid overload 1.
Why Not the Other Options
Option B (Peaked P waves): Peaked P waves indicate right atrial enlargement (P pulmonale), typically seen in chronic pulmonary disease, not acute presentations of ESRD with fluid overload 1.
Option C (Short PR interval): Short PR intervals suggest pre-excitation syndromes (e.g., Wolff-Parkinson-White) or accelerated AV conduction—unrelated to ESRD or fluid overload 1.
Option D (Narrow QRS complex): This is actually the normal finding. In hyperkalemia, the QRS widens as potassium levels increase further. A narrow QRS would not be the "most likely finding" in this clinical scenario 1.
Additional ECG Abnormalities in ESRD Patients
While peaked T waves are most likely given the acute presentation, chronic ECG abnormalities are highly prevalent in hemodialysis patients 1:
- Left ventricular hypertrophy (19%) from chronic volume overload and hypertension 1, 3
- Non-specific ST-T changes (6%) 1
- Evidence of ischemia (7.2%) 1
- Atrial fibrillation (5.4%) 1
Critical Clinical Pitfall
Do not delay obtaining an ECG and checking serum potassium in any ESRD patient presenting with dyspnea or volume overload. Hyperkalemia can rapidly progress to fatal arrhythmias, and peaked T waves warrant immediate potassium measurement and treatment if elevated 1. The combination of diabetes, ESRD, and potential use of ACE inhibitors or ARBs further increases hyperkalemia risk 1, 4.
Serial ECG monitoring is appropriate for hospitalized ESRD patients with severe electrolyte abnormalities or new acute renal failure 1.