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End-stage renal disease (ESRD) affects more than 10% of the world population. ESRD patients present impaired potassium homeostasis, which increases the risk for ventricular arrhythmias and sudden cardiac death. Noninvasive estimation of serum potassium, [K + ], before the patient experiences serious consequences is of major importance. In this study, we investigated the relationship of [K + ] with three T-wave morphological descriptors: the T-wave width (T w ), slope-to-amplitude ratio (T SA ) and temporal morphological variability (d w ) from ECGs of 12 ESRD patients undergoing hemodialysis and from simulated ECGs. Spearman&#x2019;s correlation coefficients between the descriptors T w , T SA  and d w  and [K + ] were &#x2013;0.5, 0. 8 and 0.65, respectively. These associations were, however, highly patient-dependent. The high inter-individual variability in T-wave morphology, particularly observed at high [K + ], was reproduced in the simulations and could be explained by differences in transmural heterogeneities, with 10% variations in the proportion of midmyocardial cells leading to changes larger than 15% in T-wave morphology. In conclusion, T-wave morphological descriptors have the potential to be used as predictors of [K + ] in ESRD patients, but their associated inter-individual variability should be taken into account, especially under hyperkalemic conditions.

Transmural Ventricular Heterogeneities Play a Major Role in Determining T-Wave Morphology at Different Extracellular Potassium Levels