Open Access Highly Accessed Research article

Effects of fluid overload on heart rate variability in chronic kidney disease patients on hemodialysis

Manuela Ferrario1*, Ulrich Moissl2, Francesco Garzotto3, Dinna N Cruz3, Anna Clementi3, Alessandra Brendolan3, Ciro Tetta2, Emanuele Gatti2, Maria G Signorini1, Sergio Cerutti1 and Claudio Ronco3

Author Affiliations

1 Department of Electronics, Information and Bioengineering (DEIB), Politecnico di Milano, P.zza Leonardo da Vinci 32, Milano, Italy

2 Fresenius Medical Care R&D, Daimlerstrasse 15, D-61352 Bad Homburg, Germany

3 San Bortolo Hospital, viale Rodolfi 37, 36100 Vicenza, Italy

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BMC Nephrology 2014, 15:26  doi:10.1186/1471-2369-15-26

Published: 4 February 2014



While fluid overload (FO) and alterations in the autonomic nervous system (ANS) such as hypersympathetic activity, are known risk factors for cardiovascular morbidity and mortality in patients on chronic hemodialysis (HD), their relationship has not been thoroughly studied.


In this observational study involving 69 patients on chronic HD, FO was assessed by whole body bioimpedance measurements before the midweek HD session and ANS activity reflected by Heart Rate Variability (HRV) was measured using 24-hour Holter electrocardiogram recordings starting before the same HD treatment. In total, 13 different HRV indices were analyzed, comprising a mixture of time domain, frequency domain and complexity parameters. A correlation analysis was performed between the HRV indices and hydration status indices. Successively, patients were retrospectively assigned to a high FO (H, FO > 2.5 L) or low FO (L, FO ≤ 2.5 L) group and these were further compared also after stratification by diabetes mellitus. Finally, a small number of patients without diabetes with significant and persistent FO were followed up for 3 months post-study to investigate how normalization of fluid status affects HRV.


SDANN, VLF, LZC and HF% parameters significantly correlate with FO (correlation coefficients were respectively r = –0.40, r = –0.37, r = –0.28 and r = 0.26, p-value < 0.05). Furthermore, LF% and LF/HF were inversely correlated with hydration status (correlation coefficients were respectively r = –0.31 and r = -0.33, p-value < 0.05). These results indicate an association between FO and reduced HRV, higher parasympathetic activation and reduced sympathetic response to the HD session. Indeed, group H tended to have lower values of SDANN, VLF and LZC, and higher values of HF% than patients in the L group. Finally, there was a trend towards lower LF% measured during the last 30 minutes of HD for the H group versus the L group. Reduction in FO achieved over 3 months by implementation of a strict fluid management plan resulted in an increase of HRV.


Our results suggest that depressed HRV is associated with fluid overload and that normalization of hydration status is accompanied by improved HRV.

Autonomic nervous system; Fluid overload; Heart rate variability; Hemodialysis; Whole-body bioimpedance spectroscopy