Pulse Waveform Records of Type 2 Diabetic Nephropathy Disease

Patients at Radial Artery Chi Area

Erni Yudaningtyas1,4, Harijono Achmad2, Rasjad Indra2, Djoko H. Santjojo3, Waru Djuriatno4
1
Doctor Candidate of Biomedical Engineering Department of Medical Faculty, Brawijaya University, Indonesia
2
Medical Faculty, Brawijaya University, Indonesia
3
Physics Department of Physical Sciences Faculty, Brawijaya University, Indonesia
4
Electrical Engineering Department of Engineering Faculty, Brawijaya University, Indonesia

Abstract

The relationship between wrist-pulse characteristics and Type 2 Diabetic Nephropathy stages was
investigated based on empirical study of radial pulse waveform. Radial pulse waveforms were measured non-
invasively from 6 healthy subjects and 36 pathological subjects that were 1, 2, 3a, 3b, 4, and 5 stages type 2 Diabetic
Nephropathy. Comparisons were made among those seven groups and a typical characteristic waveform was found
in healthy group. The pulses in type 2 Diabetic Nephropathy had 6 characteristics.
Keywords: Pulse waveform, TCM pulse diagnosis, radial artery chi area, type 2 Diabetic Nephropathy

INTRODUCTION Pulse palpation in western medicine and TCM has

World Health Organization (WHO) report in 2005
showed that the number of death in the entire world
population was 58 million, of which 35 million
(approximately 60%) of such diseases was caused by
chronic diseases.1 One of these was the Chronic Kidney
Disease (CKD), where approximately 26 million
Americans suffered from CKD2 and this number was
predicted would increase by 40% in the year of 2010.3
More than 500,000 patients treated at later stages of
CKD required hemodialysis or kidney transplant to
maintain life. American citizens who died from kidney
failure reached nearly 88,000 inhabitants per year.2
Similar condition also occurred in Indonesia, in dr.
Soetomo Surabaya hospital, for instance, the number of
new CKD patient undergoing hemodialysis between
2000-2006 was 973. New CKD patients increased almost
eight times in 2004-2006.4 In the period of 1996-2006,
the major cause (more than 50%) of CKD in the United
States was known as type 2 diabetes or type 2 Diabetic
Nephropathy.
Due to Chronic Kidney Disease (CKD) often does
not show symptoms, it is often undetectable even to
patients who have health access5,6. Patient treatment at an
early stage of CKD and its complications could be
slowed down in its development into the end-stage.
Based on this, early detection of CKD patient is
extremely needed, particularly through the method of
periodically blood and urine examination. On the
condition of non-invasive method to detect CKD exists,
periodically examination would be in great demand by
public. This non-invasive method is usually performed in
Traditional Chinese Medicine (TCM) using pulse
palpation.
been applied at the radial artery pulse.7 TCM pulse
diagnosis is widely used for diagnostic, pathology,
physiology, and research.8 Pulse palpation method is one
of the most important diagnostic tool in TCM9 consists
of general and cun, guan, chi pulse. In general pulse
examination, the technique and interpretation are similar
to the pulse in western medical science in determining
frequency, rhythm, and pulse amplitude. The cun, guan,
chi pulse is not known in western medicine, but this
pulse examination is very useful to recognize the
existence of certain diseases, including kidney diseases.10
TCM pulse examination is obtained by deep-pressing a
blood vessel at radial artery area. Based on the
preliminary study the pressure exerted at radial artery
area in order to obtain the best pulse waveforms was 150
mmHg in accordance with skin thickness.
Pulse at radial artery area (Figure 1) reflects the
state of some organs.7
Figure 1 Radial artery pulse area. Area cun, guan, and chi is used to
detect abnormalities or disorders of heart, liver, and kidney organs.7
More training and higher concentration are required
in TCM pulse palpation skill.11 By analyzing pulse rate
fluctuation disease symptoms that can not be obtained
only through Electrocardiograph (ECG) examination will
be detected and predicted. In addition, pulse examination
is recommended by WHO because it is simple,
inexpensive, requires no blood, non-invasive, and is a
method that does not have side effect.12 Pulse diagnosis
method has been proved clinically correct and useful for
more than 5000 years12,13 and is used to determine patient
pathological condition.7
A research on cun, guan, chi pulse waveform in
TCM had been applied in patients with CKD who had
such hypertension histories14. The research produced
five types of pulse waveforms. However, the relationship
between pulse waveform and the seriousness of
condition or the stage of CKD is still unknown.
Guidelines for Kidney Disease Outcomes Quality
Initiative (K/DOQI) of Canadian National Kidney
Foundation (NKF)15 will be used to detect and evaluate
CKD which consists of disease definition and the stage
of CKD.
The objective of this present study is to investigate
the relationship between the stage of CKD patients
caused by type 2 diabetes or type 2 Diabetic
Nephropathy at various stages and the results of pulse
waveform records at left hand radial artery chi area.
Recording was executed by using a detection instrument
and non-invasive pulse waveform recording.
METHODS
The first step was screening of healthy and
pathological subjects of type 2 Diabetic Nephropathy
which consisted of age, sex, and body mass index (BMI).
After that examined the results of medical record of
blood pressure, the presence of proteinuria, and serum
creatinine level of CKD patients. The definition of CKD
derived from the guidelines for K/DOQI of NKF defines
CKD as a kidney damage for 3 months or more based on
the presence of abnormal structures or functions (urine,
blood examination) or Glomerular Filtration Rate (GFR)
measurement <60 mL/min/1, 73 m2 for three months or
more with or without kidney damage. K/DOQI classifies
the stages of CKD into five (Table 1).15
Table 1 Relationship between GFR and CKD stage15
CKD Kidney Failure Mean GFR(ml/menit/1.73m2)
Stage
1 Normal Kidney Function >90
2 Increased Risk 60-89
Early Stages of Kidney
3a 45-59
Disease
Medium Stages of
3b 30-44
Kidney Disease
4
Advanced Stages of
15-29
Kidney
5 Kidney Failure <15
GFR measurement outcome was obtained through
the research result equation of Modification of Diet in
Renal Disease (MDRD), which had been widely used to
determine GFR in kidney patients with diabetes, chronic
kidney patients aged approximately 51 years, patients
with kidney transplants, and dark skinned CKD patients
with hypertension.16
This study was an analytic observational (non-
experimental) research with cross-sectional approach,
with the consideration that Chronic Kidney Disease
(CKD) have a long latent period to identify several risk
factors simultaneously. This approach would seek the
relationship between independent variables (risk factors)
and dependent variables (effects) by executing
observation (by pulse waveform recording)
simultaneously at the same time.17
Subjects
The research subjects were 6 healthy female adults
and 36 Diabetic Nephropathy pathological female
groups. They aged 55 ± 4 years old with normal BMI
from 18.5 to 25.0, normal blood pressure of 110-130/70-
90 mmHg, the presence of albuminuria, and serum
creatinine levels > 0.9 mg/dl.
Techniques
Pulse waveform was detected and recorded non-
invasively in radial artery cun and chi areas through a
316L SS Model 86 Ultrastabil pressure sensor suitable
for low pressure applications18 that connected with data
acquisition system. To ensure the sensor not to shift from
its position child sphygmomanometer cuff was used at
wrist and used to suppress the chi area.
Pulse waveform recording was carried out under
rest condition where the research subjects had been
sitting for five minutes. When the pulse was examinated,
examiner breathing was set to adjust the research subject
pulse. Furthermore, searching of pulse area was executed
at left hand radial artery chi area.
First was placed the area of guan with middle
finger in front of styloid process, then determined the chi
position (proximal to guan with a distance of
approximately one cun) and put a pressure sensor that
was connected with the pulse waveform recording device
in radial artery cun area. Then child sphygmomanometer
cuff was sticked to the pressure sensor and provided with
about 150 mmHg pressure to find the best pulse
waveform. Furthermore, recording process was carried
out for about 20 seconds.
Sampling data with a frequency of 100 Hz (100
samples in sampling process within 1 second or sampling
was carried out per 10 milliseconds) with the result that
2000 digital data were obtained within 20 seconds. With
2000 digital data it would obtain approximately 25 pulse
waveforms (if the pulse frequency was 75 bpm). The
pulse waveform considered as amplitude waveform as a
time function.
Pulse Waveform Selection
The pulse waveform selection was derived from
data in several pressures exerted at radial artery chi area.
Data selection was performed to find the best pulse
waveform, the ones which had the most obvious The pulse waveform for pathological subjects of
waveform and the highest amplitude. stage 2 type 2 Diabetic Nephropathy was shown in
Figure 4.
Study of Pulse Waveform
Research subject data in time domain obtained from
the pulse recording results were classified based on the
results of CKD stage grouping.

Time Required for Systolic Ejection

The time required for systolic ejection was
estimated based on time disparity between pulse lowest
amplitude (diastolic) and pulse highest amplitude
(systolic).
Figure 4 Stage 2 Type 2 Diabetic Nephropathy Pathological Subject
Pulse Waveform Records. Time required for systolic ejection was
RESULTS
approximately 0.25 s and irregular.

Pulse waveform records in healthy subjects had

similar pulse waveform. Pathological subjects of type 2 The pulse waveform for pathological subjects of
Diabetic Nephropathy had six different waveform stage 3a type 2 Diabetic Nephropathy was shown in
patterns which different from healthy subjects. However, Figure 5.
a similar waveform was obtained in subjects with type 2
Diabetic Nephropathy in the same stage.
In pulse waveform recording at the radial artery chi
area in time domain, the healthy subjects had a pulse
waveform as in Figure 2.

Figure 5 Stage 3a Type 2 Diabetic Nephropathy Pathological Subject

Pulse Waveform Records. Time required for systolic ejection was
approximately 0.4 s.

The pulse waveform record of pathological subjects

with stage 3b type 2 Diabetic Nephropathy at radial
Figure 2 Healthy Subjects Pulse Waveform Records. Time required
for systolic ejection was approximately 0.15 s. artery chi area in time domain was shown in Figure 6.

The pulse waveform for pathological subjects of

stage one type 2 Diabetic Nephropathy was shown in
Figure 3.

Figure 6 Stage 3b Type 2 Diabetic Nephropathy Pathological Subject

Pulse Waveform Records. Time required for systolic ejection was
approximately 0.5 s.

Figure 3 Stage 1 Type 2 Diabetic Nephropathy Pathological Subject The pulse waveform records of pathological
Pulse Waveform Records. Time required for systolic ejection was subjects with stage 4 type 2 Diabetic Nephropathy at
approximately 0.2 s.
radial artery chi area in time domain was shown in
Figure 7.
Figure 7 Stage 4 Type 2 Diabetic Nephropathy Pathological Subject
Pulse Waveform Records. Time required for systolic ejection was
approximately 0.6 s.
The pulse waveform record of pathological subjects
with stage 5 type 2 Diabetic Nephropathy or renal failure
at radial artery chi area in time domain was shown in
Figure 8.
Figure 8 Stage 5 Type 2 Diabetic Nephropathy Pathological Subject
Pulse Waveform Records. Time required for systolic ejection was
approximately 0.8 s.
DISCUSSION
The beginning of a heartbeat until the end is known
as a cardiac cycle. A cardiac cycle consists of a period of
relaxation called diastole, a blood filling period followed
by a period of contraction called systolic.19 When the
heart contracts, blood is pumped into the aorta so that the
aortic pressure occurred is widened and delivered as a
waveform through the aorta and all its branches. This
waveform results in the emergence of several harmonic
waveforms which provide a cumulative effect. Forward
movement of blood pressure follows the pressure
waveforms path, which together with harmonic
waveforms, and by widening and lengthening resulting
in artery is the pulse we can palpate.20
Regular pulse measurement is performed at right or
left wrist radial artery because it is superficial. Changes
in arterial pulse is proportional to body condition which
is strongly influenced by the cardiovascular system
work21, where the majority of cardiovascular diseases are
related to hemodynamic system dysfunction.
Organ function is highly dependent on adequate
blood flow. Cardiac contraction raises the pressure on
blood which is the main driving force of blood flow
through blood vessels. Due to the friction between
moving fluid and blood vessels walls, the resistance (R)
of blood vessels occurs, and blood pressure descends
throughout the blood vessels. Blood viscosity, length of
blood vessels, and blood vessels diameter influenced
blood vessels resistance.22
Hemorheology is a study of blood flow effects on
cellular components and blood vessel walls.23 Blood
elements consist of plasma (yellowish liquid), red blood
cells (erythrocytes), white blood cells (leukocytes) and
platelets (thrombocyte). Blood flow significantly
contributes to disease process.24 Hemorheology is
complex and mainly determined by several variables
such as blood viscosity, hematocrit, deformability, and
erythrocytes aggregation.25 Rheology parameters are
illustrated as blood viscosity that affects blood flow in
blood vessels.26
Blood viscosity is determined by plasma viscosity,
hematocrit (percentage of erythrocytes in blood), and
mechanical properties of erythrocytes.27 Patients with
diabetes in a number of studies show increases in blood
viscosity, erythrocytes suspension, and erythrocytes
deformability change.26 High deformability of red blood
cells result slower blood circulation and facilitate the
formation of thrombocyte in stiff artery wall in such a
way that circulation disorder occurs.28
Viscosity corresponds with the level of friction
among fluid molecules at fluid flow. Blood viscosity is
strongly determined by the amount of circulating red
blood cells. Higher viscosity would increase the blood
vessels resistance. 22 Enlarged blood vessels resistance
would decrease blood flow rate.29
Type 2 Diabetic Nephropathy disease is detected by
the existence of protein in urine secretion and decreasing
kidney function that is represented in the abnormality of
serum creatinine or GFR.30 Clinically, type 2 Diabetic
Nephropathy is characterized as the increase of
proteinuria and the decrease of GFR. A Type 2 Diabetic
Nephropathy patient has above normal blood sugar and
serum creatinine levels, and the increase of erythrocytes
in his/her blood31 could increase blood viscosity. When
there is excessive erythrocytes, the blood flow becomes
more inertial.21
That inertial blood flow could be seen from the
difference in time required for systolic ejection from
diastolic. In healthy subjects, the time required for
systolic ejection corresponded to the time of half heart
muscle contraction (0.25-0.3) s,21 that was about (0.125-
0.15) s. For stage 1 pathological subjects, the pulse
waveform was normal but the time required for systolic
ejection took place more slowly, which was
approximately 0.2 s. For stage 2 pathological subjects,
the pulse waveform was irregular and the time required
for systolic ejection was approximately 0.25 s. In stage
3a pathological subjects, the pulse waveform was
irregular and the time required for systolic ejection was
approximately 0.4 s. In stage 3b pathological subjects,
the pulse waveform was irregular and the time required
for systolic ejection reached 0.5 s. For stage 4
pathological subjects, the pulse waveform was irregular
and the time required for systolic ejection reached 0.6 s.
Finally for stage 5 pathological subjects, the pulse
waveform was irregular as well, and the systolic ejection
was nearly flat with diastolic’s and the time required for
systolic ejection was approximately 0.8 s. This indicated
that the higher the stadium of type 2 Diabetic
Nephropathy disease or the higher the creatinine level,
the more inertial the blood flow.
CONCLUSION
Recording results showed the more serious or the
higher stage level of type 2 diabetes nephropathy
disease, the more inertial the pulse waveform at the
radial artery chi area with the result that the longer the
time needed for systolic ejection which was varied from
0.2 s to 0.8 s.
REFERENCES
1. World Health Organization (WHO) Global Report.
2005. Preventing Chronic Diseases: A Vital
Investment, (Online),
(www.who.int/chp/chronic_disease_report/contents/
en/index.html, diakses 5 Agustus 2009.
2. US Renal Data System. 2008. USRDS 2008 Annual
Report: Atlas of Chronic Kidney Disease and
Endstage Renal Disease in the United States.
National Institutes of Health, National Institute of
Diabetes and Digestive and Kidney Diseases,
Bethesda, MD.
3. Coresh, J., Selvin, E., Stevens, L.A., Manzi, J.,
Kusek, J.W., Eggers, P., Van Lente, F. & Levey.
2007. A Prevalence of chronic kidney disease in the
United States. JAMA, 298: 2038-2047.
4. Santoso, D., Pranawa, Yogiantoro, M., Thahal, M.,
Widodo, Wardana, Mardiana N., Irwanadi, C.,
Soewanto, & Tomino, Y. 2007. The Varying
Numbers of New Cases of Hemodialysis Patients in
East Java, Indonesia: An Observation of The
Increasing and Decreasing Numbers in Relation to
Socio- Economic Condition. Hamamatsu, Japan:
Abstracts (5-14) Asian Forum of CKD initiative,
(Online), (http://www.jsn.or.jp/AFCKDI2007/,
diakses 25 Maret 2010).
5. National Kidney Foundation. 2003. KEEP: Kidney
Early Evaluation Program. Annual data report.
Program Introduction. Am J Kidney Dis, 42(5 suppl
4):S5-15, (Online),
(http://www.kidney.org/keep/pdf/ajkd_KEEP_nov_
2003.pdf.
6. McClellan, W.M., Ramirez, S.P., & Jurkovitz C.
Screening for chronic kidney disease: unresolved
issues. J Am Soc Nephrol:14(7 suppl 2):S81-7.
7. Liangyue, D., Yijun, G., Shuhui, H., Xiaoping, J.,
Yang, L., Rufen, W., Wenjing, W., Xuetai, W.,
Hengzhe, X., Xiuling, X. & Jiuling, Y. 2003.
Chinese Acupuncture and Moxibustion. Foreign
Language Press. Beijing.
8. Xu, L., Wang, K., David, Z, & Shi, C. 2002. Proc. of
the 15 th IEEE Symposium on Computer-Based
Medical System (CBMS), 1063-7125/02.
9. Alternative Medicine Foundation, Inc. 2006.
Introduction - A Brief History of TCM (Traditional
Chinese Medicine). Potomac Maryland, (Online),
(http://www.amfoundation.org/tcm.htm#DIAGNOSI
S, diakses 22 Maret 2007).
10. Gendo U. 2006. Teori Kedokteran Tradisional Cina.
Yogyakarta. Kanisius.
11. Mother Nature, Inc. Natural Product – Health
Advice. 2007. Traditional Chinese Medicine,
(Online),
(http://www.mothernature.com/Library/Bookshelf/B
ooks/46/29.cfm, diakses 15 Maret 2007).
12. Xu, L., Wang, K., Zhang, D., Li, Y., Wan, Z. &
Wang, J. 2003. Objectifying Researches on
Traditional Chinese Pulse Diagnosis. Informatica
Medica Slovenica, 8(1): 56-63.
13. Wang, K., Xu, L., Zhang, D. & Shi C. 2002. TCPD
Based Pulse Monitoring and Analyzing. Proceeding
of the First International Conference on Machine
Learning and Cybernetics, Beijing.
14. Lau, E.O.Y. & Chwang, A.T. 1998. Relationship
between Wrist-pulse Characteristics and Body
Conditions. Department of Mechanical Engineering,
The University of Hongkong.
15. National Kidney Foundation. 2002. Kidney Disease
Outcomes Quality Initiative (K/DOQI) Clinical
 Practice Guidelines for Chronic Kidney Disease:
Evaluation, Classification, and Stratification.
16. Snyder, S. & Pendergraph, B. 2005. Detection and
Evaluation of Chronic Kidney Disease, Am Fam
Physician, 72: 1723-1732.
17. Sastroasmoro, S. & Ismael, S. 2002. Dasar-dasar
Metodologi Penelitian Klinis (Edisi kedua). Jakarta:
Sagung Seto.
18. Measurement Speciliates, Inc. Model 86 Ultrastable
Pressure Sensor. 1000 Lucas Way Hampton, VA
23666 USA, (Online), (www.meas-spec.com,
diakses 6 Januari 2008).
19. Guyton, A. & Hall, E.J. 2006. Textbook of Medical
Physiology. Philadelphia: Elsevier Saunders.
20. Delp, M. H. & Manning, R. T. 1996. Major’s
Physical Diagnosis An Introduction to the Clinical
Process, 1981. Philadelphia: W.B. Saunders
Company. Moelia Radja Siregar (penterjemah).
1991. Major Diagnosis Fisik (Edisi IX). Jakarta:
EGC.
27. Baskurt, O.K. & Meiselman, H.J. 2003. Blood
rheology and hemodynamics. Seminars in
Thrombosis and Haemostasis, 29: 435–450.
28. Armstrong, D. & Lawrence, A. 1998. A . Diabetic
Food Ulcers, Prevention, Diagnosis and
Classification, (Online),
(http://www.aafp.org/afp/980315ap/armstron.html,
diakses 27 Juni 2007).
29. Stoltz, J.F. & Donner, M. 1987. Hemorheology:
Importance of erythrocyte aggregation. Clin
Hemorheol, 7 (15).
30. Rehman, G., Khan, S.A., & Hamayun, M. 2005.
Studies on Diabetic Nephropathy and Secondary
Diseases in Type 2 Diabetes. INT. J. DIAB., 25,
(Online), (http://www.rssdi.org/2005_jan-
mar/original_article3.pdf, diakses 19 April 2010).
31. Demiroglu, H. & Gürlek, A. 1998. Altered red blood
cell rheology as a predisposing factor for diabetic
nephropathy. Nephron, 79(1):121-2.

21. Mitchell, F.G, Tardif J.C., Arnold, J.M.O, Marchiori,

G. , O’Brien, T.X., Dunlap, M.E., & Pfeffer M.A.
2001. Pulsatile Hemodynamics in Congestive Heart.
Hypertension, 38:1433-1439, (Online),
(http://hyper.ahajournals.org/, diakses 10 April
2010).

22. Sherwood, L. 2010. Human Physiology From Cells

to System (7th ed.). BROOKS/COLE CENGAGE
Learning.

23. Farlex. 2009. Mosby’s Medical Dictionary (8th. ed),

(Online),
(http://medicaldictionary.thefreedictionary.com/hem
orheology, diakses 15 April 2010).

24. Baskurt, O.K., Hardeman, M., Rampling, M.W., &

Meiselman, H.J. 2007.. Handbook of Hemorheology
and Hemodynamics. Amsterdam: IOS Press.

25. Resch, K.L., Ernst, E., Matrai, A., Buhl, M.,

Schlosser, P., & Paulsen, HF. 1991. Can rheologic
variables be of prognostic significance in
arteriosclerotic disease? Angiology, 41:963.

26. Baskurt, O.K. 2003. Pathophysiological Significance

of Blood Rheology. Perspective in Medical
Sciences. Turk J Med Sci., 33: 347-355.