|Year : 2018 | Volume
| Issue : 4 | Page : 261-265
To study auditory functions in chronic kidney disease
Kapil Kumar Singh1, Arvind Trivedi2, Nikunj Jain1, Mohd Irteza2
1 Department of ENT, LLRM Medical College, Meerut, Uttar Pradesh, India
2 Department of Medicine, LLRM Medical College, Meerut, Uttar Pradesh, India
|Date of Web Publication||15-Mar-2019|
Dr. Nikunj Jain
4/19, Shradha Puri Phase-1, Kanker Khera, Meerut Cantt - 250 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Chronic kidney disease (CKD) is worldwide public health problem with a rapidly expanding disease burden. In CKD, auditory damage occurs both at the sensory organ and the neuronal level. The incidence of hearing loss has been found to be higher in patients suffering from CKD as compared to the general population in various studies conducted so far. Bazzi et al. reported hearing loss in 77% of the CKD patients tested by them.
Keywords: Chronic kidney disease, hearing loss, pure-tone audiometry, transient-evoked otoacoustic emission
|How to cite this article:|
Singh KK, Trivedi A, Jain N, Irteza M. To study auditory functions in chronic kidney disease. Indian J Otol 2018;24:261-5
| Introduction|| |
The etiological factors are numerous for sensorineural deafness in this population of the patients and remain controversial even today. Ototoxic drugs, uremic toxins, metabolic disturbances, changes during hemodialysis, and other modes of renal replacement therapy in end-stage renal failure patients have been proposed in the literature as the possible causes of hearing loss in these patients.
Given the high prevalence of hearing loss in these patients, a routine audiological assessment for these patients is essential.
The aim of this study is to evaluate the auditory functions in patients of chronic kidney disease (CKD) and the effects of the various treatment modalities on the same.
Similarities between the cochlea and the kidney
Many anatomical, physiological, pharmacological, and pathological similarities exist between the nephron and stria vascularis of the cochlea, and there are many similarities at the ultrastructural level.
Both contain epithelial structures in close contact with their vascular supply. In addition to this basement membrane-lined intercellular channels exist both in the glomerulus and the stria vascularis.
Both the inner ear and kidney are involved in body fluid homeostasis, namely, active transport of fluid and electrolytes accomplished by stria vascularis and glomerulus, respectively, and therefore have epithelium containing a Na+-K+ ATPase, carbonic anhydrase.
Furthermore, it has been shown that there is immunological connection between kidney and inner ear in that antibodies against the nephron also deposit in stria vascularis.,
Etiology of hearing loss in chronic kidney disease
Several etiological factors have been linked to hearing loss in renal failure including the use of ototoxic drugs, electrolyte disturbances, hypertension, and hemodialysis.,
Adler et al. found a significant reduction of Na+-K+-activated ATPase in the inner ear of uremic guinea pigs, and inhibition of this enzyme system in the cochlear cells was proposed to be a factor in inner ear dysfunction among uremic patients.
Di Paolo et al. indicated very high incidence of nerve conduction dysfunction in chronic renal failure patients. In agreement with these studies, several auditory brain stem response studies of CRF patients indicated dysfunction of the auditory nerve and the rest of the auditory pathway.
More than 130 compounds are known to be ototoxic, those most commonly used in clinical practice are aminoglycoside antibiotics, diuretics (ethacrynic acid and furosemide), anticonvulsants (phenytoin and ethosuximide), beta-blockers (propranolol and oxprenolol), antiheparinizing agents (hexamethonium bromide), cytotoxic drugs (cisplatin and nitrogen mustard), and others (thalidomide, salicylates, and quinine). Ototoxic drugs exert their effects predominantly on one of the portions of the inner ear. The three main sites, where ototoxic drugs act, are the cochlea, the vestibulum, and the stria vascularis.
Among the CKD population, the drugs most commonly used are the diuretics. Ethacrynic acid was the first potent diuretic shown to cause hearing loss.
Frusemide unlike ethacrynic acid is not exclusively excreted by the kidney. Quick et al. reported hearing loss when furosemide was given rapidly and repeatedly and suggested to abandon the policy of rapid push of the drug.
Effects of dialysis
Hemodialysis can result in multiple complications such as acute hypotension, reduction in blood osmotic pressure, acute clearance of urea, increased RBC mass, and immunological reaction to dialyzer that can all lead to hearing loss.
Combined effects of acute fluid removal and hypotension may lead to production of microemboli within the capillary system, especially in the cochlea.
Strial dysfunction would impair selective ion transport and cause diminished production of endolymph with collapse of Reissner's membrane.
| Materials and Methods|| |
The proposed study was conducted in the Department of ENT and Medicine in LLRM Medical college, Meerut, Uttar Pradesh, India.
Based on the patient profile, we categorized the patient into two groups as follows:
- Patients of stage 3, 4, and 5 CKD on conservative management
- Patients on maintenance hemodialysis for >1 month.
- Male or female patients suffering from CKD
- Age group 20–60 years
- Patients giving written informed consent.
- Inability to understand written informed consent
- Patients with a history of otological disease, ear trauma, noise exposure, and ototoxic drugs except diuretics.
A careful history was taken in all patients with special emphasis on the use of diuretics and other ototoxic drugs, diabetic status, and duration of hemodialysis wherever applicable.
All patients were enquired regarding otologic symptoms.
A detailed systemic and local ENT examination was done. All patients included in the study went through routine biochemical investigation, i.e., hemogram, kidney function tests, serum calcium, phosphate and albumin, and radiological evaluation, i.e., ultrasound of kidney, ureter, and bladder.
The local ENT evaluation was done to rule out external and middle ear causes of hearing loss.
After that, the patients were subjected to pure-tone audiometry (PTA), and hearing thresholds were recorded for both ears at 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz, 6000 Hz, and 8000 Hz. The PTA was the interpreted for the type and the severity of hearing impairment. The WHO grading which was used to measure the severity of hearing loss.
The patients who were found to have normal hearing threshold at speech frequencies were subjected to the more sensitive transient-evoked otoacoustic emissions (TEOAEs). The patients whose TEOAEs were normal in both ears were considered to have a normal hearing and those who had absent TEOAEs were considered to be at high risk for hearing loss in future.
Data analysis was done with the Statistical Package for the Social Sciences (IBM India Private Limited, Bangalore, India) using univariate analysis by the Chi-square test. Results were considered statistically significant when the observed P < 0.05.
| Results|| |
Over the period, 65 patients aged 20–60 years with CKD were screened for the presence of hearing loss. Ten patients were had a conductive hearing loss and hence were excluded from the study. Data were analyzed for the prevalence of hearing loss in the study population of 55 patients who participated in the study after a written informed consent. An assessment of clinical and biochemical variables that could be associated with hearing loss in CKD patients was also made.
The study population consisted of 55 patients with a mean age of 40.96 + 9.4 years with a range of 20–56 years.
Thus, the maximum number of patients was in the 40–49 years age group and the minimum in 30–39 years group.
There were 22 (40%) female patients and 33 (60%) male patients.
Prevalence of otological symptoms in the study population
In the study population of 55 patients, deafness was reported by 14 patients, tinnitus by 4 patients, and only 5 patients complained of vertigo.
Prevalence of hearing loss in study population
Among the 55 patients enrolled in the study, 39 (70.9%) patients had bilateral sensorineural hearing loss (SNHL). The remaining 16 patients either had a normal PTA result or had evidence of hearing loss only at higher frequencies.
Results of pure-tone audiometry
All the 55 patients enrolled in the study underwent a pure-tone audiometric evaluation.
Results of transient-evoked otoacoustic emissions
TEOAEs were done only for patients who had no hearing loss according to the WHO guidelines, i.e., patients who either had a normal PTA or had only high-frequency hearing loss. Out of 16 patients tested, TEOAEs were found to be present in 6 patients whereas no TEOAEs were detected in rest of the 10 patients.
Thus, 10 of 16 (62.5%) patients with no hearing loss by PTA had absent TEOAEs and thus should be considered at high risk of developing hearing loss in the future.
Comparison of various clinical and biochemical parameters in patients with and without hearing loss
The mean age of patients with hearing loss is 43.69 ± 7.64 years as compared to 34.3 ± 9.72 years in those without hearing loss with P = 0.004 between the two groups and is statistically significant.
Thus, the prevalence of hearing loss is increasing with increasing age, and P value between groups is 0.004 and is statistically significant.
The hearing loss was found to be comparable between males (69.7%) and females (72.7%), and P value was 0.808 which is statistically not significant.
Thus, 93.4% of all diabetic patients had evidence of hearing loss as compared to 41.6% in the nondiabetic group. P value is <0.001 and is statistically significant.
Thus, 81.8% of all hypertensive patients had evidence of hearing loss as compared to 27.3% in the nonhypertensive group. The value of P is <0.001 and is statistically significant.
Thus, 83% of patients on diuretics were suffering from hearing loss as compared to 35.71% in the group not on diuretics. P value is <0.001 and is statistically significant.
Comparison of hearing loss between different treatment groups
Among the 55 CKD patients enrolled in the study, 30 patients were on conservative medical management and 25 patients were on hemodialysis. The prevalence of hearing loss was 73.3% in the patients on conservative treatment and 68% in the hemodialysis patients.
P value is 0.4 and is not statistically significant.
| Discussion|| |
In the present study, the mean age of the study population was 40.96 ± 9.4 years [Table 1]. A study enrolled 22 (40%) female and 33 (60%) male patients. Diuretics were a part of treatment regimen of 41 (74.54%) patients.
Otological symptoms were reported by small number of patients. Fourteen patients complained of deafness, four complained of tinnitus, and vertigo was reported by five patients [Table 2].
The prevalence of SNHL in patients with CKD is higher than the general population, and it has been reported by quite a good number of studies. The hearing loss is of the sensorineural type and results from inner ear dysfunction in these patients. Bazzi et al. reported mild-to-moderate SNHL among 77% of the CKD patients.
Ozturan and Lam found a moderate-to-severe hearing loss in 46% of the tested patients. Vilayur et al. in their large population-based study reported a high prevalence of 54% hearing loss associated with moderate CKD.
Bergstrom and Thompson reported hearing loss in 47% of the 151 end-stage CKD patients. Charachon et al. reported that 75% of the 54 CKD patients tested had hearing loss.
Johnson and Mathog noted high-frequency hearing loss in 61 adults.
Stavroulaki et al. recorded SNHL of unknown etiology in 55% of renal patients mainly in higher frequencies.
Lasisi et al. found SNHL in 67% of patients with CKD.
In the present study, bilateral SNHL was detected in 71% of the patients [Table 3]. This is much higher than the prevalence of hearing loss in general adult population.
The mean hearing threshold in the patients with hearing loss at lower frequency (500 Hz) and higher frequencies (4000 Hz, 6000 Hz, and 8000 Hz) was relatively higher than the middle frequencies (1000 Hz and 2000 Hz) suggesting the predilection for involvement of low and high frequencies in CKD patients with the relative sparing of middle speech frequencies.
Gatland et al. reported similar findings with the incidence of deafness as 41% in low frequencies, 15% in mid frequencies, and 53% in higher frequencies.
However, Johnson and Mathog and Antonelli et al. reported only high-frequency hearing loss in CKD patients.
The patients who had either a normal PTA or had only high-frequency hearing loss were further tested by the more sensitive TEOAEs.
TEOAEs were absent in the patients who had only high-frequency hearing loss on PTA. TEOAEs were also absent in 9 of 15 patients who had normal PTA. Thus, a normal PTA but the absence of TEOAEs in these patients indicates that these patients may not have hearing impairment presently but are at high risk for the same in the future and need careful monitoring [Table 4].
|Table 4: The results of transient-evoked otoacoustic emissions in patients with no hearing loss|
Click here to view
Sobh et al. also reported a similar increase in the sensitivity of detection of SNHL in these patients with the use of TEOAEs.
In the present study, a number of clinical and biochemical variables were analyzed between CKD patients with and without hearing loss. The mean age of patients with hearing loss is 43.69 ± 7.64 years as compared to 34.3 ± 9.72 years in those without hearing loss [Table 5]. The difference was statistically significant with P = 0.004.
|Table 5: The distribution of patients with and without hearing loss in the different age groups|
Click here to view
Sex did not affect the hearing loss, and it was comparable between males and females.
The prevalence of hearing loss was also higher in the diabetic patients with P < 0.001.
Rajendra et al. reported hearing loss in 73% of the type 2 diabetes patients tested.
A comparison was also made between the hearing loss in hypertensive and nonhypertensive patients, and significantly higher hearing loss was recorded in the hypertensive group with P value = 0.001. The hearing loss was also significantly higher in the patients on diuretics with P = 0.001.
Thus, the present study indicates that the prevalence of hearing loss increases with age, diabetes, hypertension, and use of diuretic drugs [Table 6], [Table 7], [Table 8]. However, still the prevalence of hearing loss in the younger, nondiabetic, nonhypertensive, and CKD patients not on diuretics is much higher than the general adult population, and thus, it can be suggested that CKD by itself predisposes to SNHL.
|Table 6: Comparing prevalence of hearing loss in diabetic and nondiabetic population|
Click here to view
|Table 7: Comparing prevalence of hearing loss in hypertensive and nonhypertensive population|
Click here to view
|Table 8: Comparing prevalence of hearing loss in patients on diuretics with those not on diuretics|
Click here to view
Vilayur et al. also made similar observations and reported significantly higher prevalence of hearing loss even in the population not on diuretics.
The prevalence of hearing loss was also compared between the two different treatment groups. The prevalence of hearing loss was 73.3% in the patients on conservative treatment and 68% in the hemodialysis patients, statistically insignificant [Table 9].
|Table 9: The distribution of hearing loss in chronic kidney disease patients according to treatment modality|
Click here to view
Mancini et al. reported a similar incidence of hearing loss in the conservative treatment and hemodialysis groups.
| Conclusion|| |
CKD is now a common clinical problem. The disease is associated with much higher prevalence of hearing loss compared to general population.
There are multiple etiological factors responsible including dyselectrolytemia, diabetes, ototoxic drugs, hypertension, and the effect of uremia on nerve conduction dysfunction itself.
The hearing loss is bilateral and of sensorineural type. The prevalence of hearing loss increases with age, but there is no sex predisposition.
Certain biochemical parameters such as serum sodium, calcium, albumin, and hemoglobin seem to be significantly associated with hearing loss in CKD.
The patients on conservative treatment have similar prevalence of hearing loss as that of the hemodialysis group.
Hearing impairment is associated with a significant impact on the physical, emotional, and social well-being of the patient. It is an invisible handicap that hampers the communication and interaction of the patients but many a times goes unrecognized by the health-care practitioner.
This study strongly recommends a routine audiological evaluation for all patients of CKD. Apart from treating the hearing impairment in such patients and providing them rehabilitation, we also need to be cautious in the future and avoid the use of ototoxic drugs in these patients. These patients should avoid noise exposure as that may lead to worsening of the auditory functions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vilayur E, Gopinath B, Harris DC, Burlutsky G, McMahon CM, Mitchell P, et al.
The association between reduced GFR and hearing loss: A cross-sectional population-based study. Am J Kidney Dis 2010;56:661-9.
Quick CA, Fish A, Brown C. The relationship between cochlea and kidney. Laryngoscope 1973;83:1469-82.
Arnold W, Weidauer H. Experimental studies on the pathogenesis of inner ear disturbance in renal diseases. Arch Otorhinolaryngol 1975;211:217.
Bazzi C, Venturini CT, Pagani C, Arrigo G, D'Amico G. Hearing loss in short- and long-term haemodialysed patients. Nephrol Dial Transplant 1995;10:1865-8.
Yassin A, Badry A, Fatt-Hi A. The relationship between electrolyte balance and cochlear disturbances in cases of renal failure. J Laryngol Otol 1970;84:429-35.
Hutchinson JC Jr., Klodd DA. Electrophysiologic analysis of auditory, vestibular and brain stem function in chronic renal failure. Laryngoscope 1982;92:833-43.
Serbetçioǧlu MB, Erdoǧan S, Sifil A. Effects of a single session of hemodialysis on hearing abilities. Acta Otolaryngol 2001;121:836-8.
Adler D, Fiehn W, Ritz E. Inhibition of Na+, K+-stimulated ATPase in the cochlea of the guinea pig. A potential cause of disturbed inner ear function in terminal renal failure. Acta Otolaryngol 1980;90:55-60.
Di Paolo B, Di Marco T, Cappelli P, Spisni C, Del Rosso G, Palmieri PF, et al.
Electrophysiological aspects of nervous conduction in uremia. Clin Nephrol 1988;29:253-60.
Quick CA. Hearing loss in patients with dialysis and renal transplants. Ann Otol Rhinol Laryngol 1976;85:776-90.
Bergstrom L, Thompson P, Sando I, Wood RP 2nd
. Renal disease. Its pathology, treatment, and effects on the ear. Arch Otolaryngol 1980;106:567-72.
Ozturan O, Lam S. The effect of hemodialysis on hearing using pure-tone audiometry and distortion-product otoacoustic emissions. ORL J Otorhinolaryngol Relat Spec 1998;60:306-13.
Bergstrom L, Thompson P. Hearing loss in pediatric renal patients. Int J Pediatr Otorhinolaryngol 1983;5:227-34.
Charachon R, Moreno-Ribes V, Cordonnier D. Deafness due torenal failure. Clinic pathological study. Ann Otolaryngol Chir Cervicofac 1978;95:179-203.
Johnson DW, Mathog RH. Hearing function and chronic renal failure. Ann Otol Rhinol Laryngol 1976;85:43-9.
Stavroulaki P, Nikolopoulos TP, Psarommatis I, Apostolopoulos N. Hearing evaluation with distortion-product otoacoustic emissions in young patients undergoing haemodialysis. Clin Otolaryngol Allied Sci 2001;26:235-42.
Lasisi AO, Salako BL, Kodiya MA, Amusat MA, Osisanya WP. Hearing threshold in patients with chronic renal failure. Saudi Med J 2007;28:744-6.
Gatland D, Tucker B, Chalstrey S, Keene M, Baker L. Hearing loss in chronic renal failure-hearing threshold changes following haemodialysis. J R Soc Med 1991;84:587-9.
Antonelli AR, Bonfioli F, Garrubba V, Ghisellini M, Lamoretti MP, Nicolai P, et al.
Audiological findings in elderly patients with chronic renal failure. Acta Otolaryngol Suppl 1990;476:54-68.
Sobh MA, El Koussi MM, Bakr MS. Value of otoacoustic emission in monitoring hearing acuity in chronic renal failure patients. Saudi J Kidney Dis Transpl 1999;10:144-7.
] [Full text]
Rajendra S, Anandha L, Mythili B, Viswanatha R. Evolution of the incidence of sensorineural hearing loss in patients with type 2 diabetes mellitus. Int J Biol Med Res 2011;2:982-7.
Mancini ML, Dello Strologo L, Bianchi PM, Tieri L, Rizzoni G. Sensorineural hearing loss in patients reaching chronic renal failure in childhood. Pediatr Nephrol 1996;10:38-40.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]