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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 25  |  Issue : 4  |  Page : 201-205

Prevalence and pattern of hearing loss in patients with chronic kidney disease in Kaduna, Northwestern Nigeria


1 Department of Otorhinolaryngology, Federal Medical Centre, Yola, Adamawa, Nigeria
2 Department of Otorhinolaryngology, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria
3 Department of Otorhinolaryngology, Aminu Kano Teaching Hospital, Kano, Nigeria
4 Department of Clinical Services, National Ear Care Centre, Kaduna, Nigeria
5 Department of Internal Medicine, Barau Dikko Teaching Hospital, Kaduna, Nigeria
6 Department of Otorhinolaryngology, University College Hospital, Ibadan, Nigeria

Date of Submission26-Aug-2019
Date of Acceptance24-Oct-2019
Date of Web Publication4-Dec-2019

Correspondence Address:
Dr. Mohammed Bello Fufore
Department of Otorhinolaryngology, Federal Medical Centre, Yola, PMB 2017, Adamawa
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_94_19

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  Abstract 


Background: Chronic kidney disease (CKD) is considered a serious public health issue, may be associated with hearing loss. Aim: This study aimed to determine the prevalence and pattern of hearing loss among adult patients with CKD in Northwestern Nigeria. Participants and Methods: This was a cross-sectional study of patients with CKD in a tertiary hospital in Northwestern Nigeria. Non-CKD population matched for age and sex were enrolled as controls. Ethical approval was obtained from relevant bodies. Informed consent was obtained. Data were obtained from clinical interview and audiometric evaluation of the participants. The data were descriptively analyzed using SPSS version 20. The Chi-square test was used, and the level of significance was set at P < 0.05. Results: Sixty patients and sixty controls participated in this study. The mean age for patients and controls was 43.2 ± 13.4 and 41.2 ± 11.3, respectively. Sixty-nine of the 120 ears of patients had hearing loss, whereas 25 of the 120 ears of the controls had hearing loss, giving a prevalence of 57.5% and 20.8% among patients and controls, respectively. Of patients with hearing loss, 97.1% had sensorineural hearing loss and the remaining 2.9% had mixed hearing loss. The hearing loss was mostly mild (75.4%) and bilateral (91.7%) mainly affecting higher frequencies (63.8%). Conclusion: This study showed that hearing loss was more prevalent among patients with CKD. In majority of the patients, the hearing loss was mild, bilateral, sensorineural, and mostly affecting higher frequencies.

Keywords: Chronic kidney disease, hearing loss, Kaduna, pattern


How to cite this article:
Fufore MB, Kirfi AM, Salisu AD, Samdi TM, Abubakar AB, Onakoya PA. Prevalence and pattern of hearing loss in patients with chronic kidney disease in Kaduna, Northwestern Nigeria. Indian J Otol 2019;25:201-5

How to cite this URL:
Fufore MB, Kirfi AM, Salisu AD, Samdi TM, Abubakar AB, Onakoya PA. Prevalence and pattern of hearing loss in patients with chronic kidney disease in Kaduna, Northwestern Nigeria. Indian J Otol [serial online] 2019 [cited 2020 Feb 24];25:201-5. Available from: http://www.indianjotol.org/text.asp?2019/25/4/201/272254




  Introduction Top


Chronic kidney disease (CKD) is defined as a “glomerular filtration rate of <60 mL/min per 1·73 m2, for >3 months, with or without kidney damage.”[1] The burden of CKD is huge, especially in developing countries where most patients present in the late stages of the disease.[2]

The prevalence of impaired kidney function was estimated to range between 10.0% and 20.0% of the adult population in most countries worldwide.[3] However, the prevalence varies across the globe. In America, the prevalence of CKD from various studies ranged between 7.0% and 8.6%.[4],[5] The prevalence of CKD in sub-Saharan Africa in a meta-analysis of 90 studies was reported as 13.9%.[6] Available studies in Nigeria have shown that the prevalence of CKD ranged between 3.6% and 19.9%.[1],[3],[7],[8]

Numerous complications associated with CKD result in decreased quality of life, and auditory dysfunction is one of its major complications.[9],[10] Hearing loss, tinnitus, and vertigo are the most common otologic symptoms in patients with CKD.[11],[12]

Studies have suggested the possibility of a link between the linings of the kidney and the inner ear.[13],[14],[15],[16],[17] The cochlea of the inner ear and the kidney have some membranes, held together by a substance called collagen, which is similar in both structure and function.[14],[15],[17] These membranes aid in maintaining the chemical balance of the fluids of the inner ear and the kidney.[15],[17] These similarities make both organs vulnerable to the same substances such as diuretics and the association between many other CKD conditions and hearing loss.[17] Various other etiologic factors have also been linked to hearing loss in patients with renal failure. These include hypertension, diabetes, electrolyte derangement, the use of nephrotoxic and ototoxic drugs, and hemodialysis (a treatment option for CKD).[15],[17],[18],[19],[20],[21],[22]

The prevalence of hearing impairment among CKD patients worldwide ranges between 28.0% and 80.0%.[11],[12],[21],[22],[23],[24] The prevalence of hearing loss among CKD patients in Nigeria ranges between 58.5% and 79.0%.[11],[25],[26] The consequences of hearing loss in this group of patients are that the hearing loss can become severe over time which in turn will negatively affect their ability to effectively communicate with other people, resulting in low self-esteem, social isolation, anger, and depression.[27]

Pure-tone audiometry is one of the most commonly used methods in investigating the effects of kidney disease on the auditory system.[20] Mild-to-moderate hearing loss is the most frequently encountered degree of hearing loss in patients with CKD,[12],[18],[21],[23] whereas sensorineural hearing loss (SNHL) is the most commonly associated type of hearing loss in patients with CKD.[13],[17],[18],[19],[23],[26] Patients with CKD would benefit from early detection of hearing loss which will allow for early rehabilitative measures to be taken (i.e. We aimed to determine the prevalence and pattern of hearing loss among adult patients with CKD in Northwestern Nigeria).


  Participants and Methods Top


This was a cross-sectional study of patients with CKD attending care services in a tertiary hospital in Kaduna, Northwestern Nigeria, between December 2017 and November 2018. Non-CKD population (clinical staff of the hospital) matched for age and sex were enrolled as controls. Convenience sampling technique was used for this study. Ethical approval was obtained from relevant bodies (MOH/ADM/744/VOL. 1/510 and HREC Ref. No. 18-0004). Informed consent was obtained from all participants, and participation was voluntary. Patients in Stage I and II kidney disease, history of ear discharge, hearing impairment preceding onset of renal pathology, family history of hearing loss, history of exposure to loud noise, previous history of ear surgery, patients who were too ill to undergo an audiometric test, and those who were below the age of 18 years were all excluded from the study. Data were obtained from clinical interview and audiometric evaluation of the participants.

The participants had pure-tone audiometry carried out in a quiet room where background conversations or noises were minimal at Barau Dikko Teaching Hospital, Kaduna. The ambient noise level of the test room was measured using a sound pressure level meter, Model TES1350A made in Taiwan. The sound level meter was placed at the level of the ear, and readings were taken at three different times. At each measurement, the sound level meter was allowed to stay for 30 s before taking the readings. An arithmetic mean of the three measurements was taken at each occasion. The mean ambient noise within the test room was 33.2 dB. A clinical audiometer (Model Graphic Digi-IS, USA) calibrated to ISO standard was used for the study.

The procedure was clearly explained to each participant before commencement. The participants that were tested were seated on a chair in the test room. The participants wore the headphones and signified on hearing the tone by pressing on a small handheld button as soon as the tone was heard. Pure tones were delivered to each ear consecutively through the earphones to test for air conduction (AC). The duration of presentation was 2–3 s. Both ears were tested for hearing impairment.

The test was first conducted for the right ear at 1000 Hz, then 2000 Hz, 4000 Hz, 6000 Hz, 8000 Hz, then 500 Hz, and 250 Hz in that order. The test started at 40 dB HL, if audible then was reduced in 10 dB steps till no response occurred, then it was increased in 5 dB steps till a response occurred, and the results were plotted. The left ear was then tested, and the same process for AC was repeated. To test for bone conduction (BC), the bone vibrator was placed on the mastoid bone of the test ear (the worse ear on AC) delivering different tones for each of the speech frequencies (500, 1000, 2000, and 4000 Hz). Masking was done when there was a 40 dB or more difference between the AC threshold of the test ear and AC threshold of the nontest ear or when there was a 15 dB or more difference between AC threshold of the test ear and the BC threshold of the same ear.

The results of the audiometric tests for each ear were recorded separately on an audiogram. For AC test, frequencies recorded include 250, 500, 1000, 2000, 4000, 6000, and 8000 Hz, whereas for BC test, the frequencies recorded include 500, 1000, 2000, and 4000 Hz. The pure-tone average was calculated for each ear at 500, 1000, 2000, and 4000 Hz.[26]

The type of hearing impairment was determined from the tracings on the audiogram. The classification of hearing threshold was as follows: normal threshold (≤25 dB), mild hearing loss (26–40 dB), moderate hearing loss (41–55 dB), moderately severe hearing loss (56–70 dB), severe hearing loss (71–91 dB), and profound hearing loss (>91 dB).[12],[18] All those with 25 dBHL or less were considered to have normal hearing thresholds, whereas those with >25 dBHL were considered to have abnormal hearing thresholds. Sound frequencies between 250 and 500 Hz were considered as low frequencies, 1000–2000 Hz as mid frequencies, and 4000–8000 Hz as high frequencies.[12],[13]

The data collected were analyzed using the Statistical Product and Service Solutions (SPSS) software IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to ascertain the frequencies and distribution of the variables. The Chi-square test was used to test for possible association. The level of statistical significance was set at P < 0.05.


  Results Top


A total of sixty patients with CKD who were age and sex matched with sixty non-CKD volunteer clinical staff as controls were assessed in this study.

The age range of the patients was 20–68 years, with a mean age of 43.2 ± 13.4, whereas the controls' age range was 23–64 years, with a mean age of 41.2 ± 11.3 years. [Table 1] shows that most of the patients (42, 70.0%) and controls (39, 65.0%) were >35 years old (age range of 36–68 years). The patients consisted of 42 (70.0%) males and 18 (30.0%) females, whereas the controls consisted of 41 (68.3%) males and 19 (31.7%) females. The male: female ratio (M: F) for the patients and controls was 2.3:1 and 2.2:1, respectively.
Table 1: Age and sex distribution of participants (patients and controls)

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[Table 2] reveals that hearing loss was present in 69 (57.5%) ears in the patient group, whereas in the control group, the hearing loss was present in 25 (20.8%) ears. The difference was statistically significant (χ2 = 33.856, P < 0.0001).
Table 2: Hearing threshold of patients and controls

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Of the 69 ears with hearing loss among the patients, majority (67, 97.1%) had SNHL and 2 (2.9%) had mixed hearing loss. Of the 25 ears with hearing loss among the controls, 24 (96.0%) had SNHL and only 1 (4.0%) had mixed hearing loss. [Table 3] shows the detail of the type of hearing loss for both patients and controls.
Table 3: Type of hearing loss among patients and controls

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Of the 69 ears of patients with hearing loss, majority (52, 75.4%) had mild degree hearing loss (26–40 dB), 15 (21.7%) had moderate degree hearing loss (41–55 dB), and the remaining 2 (2.9%) ears had moderately severe degree hearing loss (56–70 dB). None of the patients had either severe (71–91 dB) or profound (>91 dB) hearing loss.

Of the 25 ears of controls with hearing loss, 21 (84.0%) had mild degree hearing loss (26–40 dB) and the remaining 4 (16.0%) had moderate degree hearing loss (41–55 dB). None of the controls had either moderately severe (56–70 dB), severe (71–91 dB), or profound (>91 dB) hearing loss [Table 4].
Table 4: Degree of hearing loss among patients and controls

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Thirty-six patients (69 ears) had hearing loss. Of those with hearing loss among the patients, 33 (91.7%) were bilateral and 3 (8.3%) were unilateral. Of the 13 controls (25 ears) with hearing loss, 12 (92.3%) had bilateral hearing loss and 1 (7.7%) had unilateral hearing loss.

Sixty-nine ears (57.5%) of the patients had one form or the other of frequency affectation compared to 25 ears (20.8%) of the controls that had one form or the other of frequency involvement. Of the 69 ears in the patient group with frequency involvement, majority (44, 63.8%) had high-frequency involvement (4000–8000 Hz), 7 (10.1%) had mid-frequency affectation (1000–2000 Hz), and 18 (26.1%) had low-frequency involvement (250–500 Hz).

Of the 25 ears of the controls with frequency involvement, 17 (68.0%) had high-frequency involvement, 2 (8.0%) had mid-frequency affectation, whereas 6 (24.0%) had low-frequency affectation. [Table 5] shows the detail of the frequencies involved in both the patients and the controls.
Table 5: Frequency range involved in both ears in the patients and controls

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  Discussion Top


The reported prevalence of hearing loss among patients with CKD ranged between 28.0% and 80.0%.[11],[12],[21],[22],[23],[24] In this study, the prevalence of hearing loss among patients with CKD was found to be 57.5% compared to 20.8% among the control group. This was found to be statistically significant (P < 0.0001). This finding was similar to that reported by Costa et al.[23] in Brazil, Rahman et al.[17] in Bangladesh, and Adekwu et al.[25] in Nigeria who reported a prevalence of 53.8%, 54.0%, and 58.5%, respectively. However, Sharma et al.[12] in India, Saeed et al.[28] in Iraq, Lasisi et al.[11] in Nigeria, and Balasubramanian et al.[24] also in India in their different studies reported a higher prevalence of 73.1%, 76.3%, 79.0%, and 80.0%, respectively. The higher prevalence of hearing loss reported in their studies may be due to the difference in methods used, being longitudinal in some of the studies (before and after hemodialysis). However, Singh-Bawa et al.,[29] Jamaldeen et al.,[21] and Meena et al.[22] all from India reported lower findings of 46.7%, 41.7%, and 28.0%, respectively, compared to this current study. This may be explained by the variation in sample sizes, possibly due to small sample sizes used in some of the studies. In general, however, CKD patients were more likely to develop hearing impairment when compared to the general population.

In this study, 57.5% of the patients had hearing loss and majority (97.1%) had SNHL. These findings were similar to other studies conducted in Egypt,[13] Albania,[19] Nigeria,[25],[26] Iraq,[28] and India.[22],[29] SNHL in CKD may be partially explained by electrolyte disturbances as well as effects of hemodialysis in this group of patients, which is known to affect the cochlear function.[13] Other possible explanations for SNHL in CKD patients include hypertension, proteinuria, and use of ototoxic medications which are associated with CKD patients and are recognized causes of SNHL.[22] Age may similarly be a confounding factor in the development of SNHL in CKD patients because of the possibility of presbycusis. Studies have shown that presbycusis can start as early as 40 years of age, and then, the prevalence increases with advancing age.[30] In this study, 70.0% of the patients were above 35 years and may be having early symptoms of presbycusis which is also a known cause of SNHL.

Majority of the CKD patients in this study had mild degree hearing loss. This is similar to the findings of Reddy et al.[18] and Jamaldeen et al.[21] in India, Costa et al.[23] in Brazil, and Saeed et al.[28] in Iraq. However, Rahman et al.,[17] Bendo et al.,[19] and Meena et al.[22] reported a more severe degree of hearing loss in their studies. Their studies revealed that patients with advanced stage of disease, longer duration of CKD, and patients on dialysis had a more severe form of hearing loss. The implication of this finding is that if CKD can be detected early and managed successfully, the more deleterious long-term effects of the disease on the inner ear could be avoided and hearing loss may be limited at worse to a mild degree.

Studies have shown that most CKD patients with hearing loss have bilateral hearing impairment.[18],[21],[22],[25] In this study, majority of the patients with hearing loss (33/36, 91.7%) had bilateral hearing loss generally with one ear having worse hearing compared to the other ear. These findings were similar to that reported by Reddy et al.[18] in India who in their study of proportion of hearing loss in chronic renal failure found 122 (96.1%) and 5 (3.9%) with bilateral and unilateral hearing loss, respectively. Other studies that reported bilateral hearing loss as the most common finding include El-Anwar et al.,[13] Bendo et al.,[19] Jamaldeen et al.,[21] Meena et al.,[22] and Sam et al.[31] The higher incidence of bilateral hearing impairment noted in CKD may be explained by vascular, biochemical, fluid, and electrolyte changes as well as immunological changes in the inner ear leading to bilateral cochlear pathology. However, Nikolopoulos et al.[32] in their study found 50.0% of the hearing loss to be bilateral and unilateral in the remaining 50.0%.

Studies have shown that hearing loss in CKD patients commonly affects the higher frequencies.[10],[17],[23],[28] However, other studies have reported that hearing loss in CKD patients affects all frequencies.[12],[21],[25],[31] This study found higher frequencies (4–8 kHz) to be more commonly involved in CKD patients with hearing loss. Similar findings were reported by Peyvandi and Roozbahany[9] in India, Govender et al.[10] in South Africa, Bendo et al.[19] in Albania, Costa et al.[23] in Brazil, Balasubramanian et al.[24] also in India, Saeed et al.[28] in Iraq, and Nikolopoulos et al.[32] in Greece. The reason for high-frequency involvement may be explained by the fact that the basal turn of the cochlea is thought to be vulnerable to certain diseases and substances such as antibiotics and ototoxic medications which may lead to disorders that appear to affect hearing in the high frequencies.[33] However, Sharma et al.[12] in India, Seo et al.[16] in Korea, Jamaldeen et al.[21] in India, Adekwu et al.[25] in Nigeria, and Sam et al.[31] also in India all reported all frequency involvement as most commonly affected in CKD patients with abnormal hearing thresholds. The reason for this may be due to fluid and electrolyte imbalance and use of several medications (some ototoxic) in patients with CKD.[25]


  Conclusion Top


This study showed that hearing loss was significantly more prevalent among patients with CKD. In majority of the patients, the hearing loss was mild, bilateral, sensorineural, and mostly affecting higher frequencies.

Acknowledgment

We wish to acknowledge Dr. Umaru Sambo Grema of National Ear Care Centre, Kaduna, for allowing us to use his own personal diagnostic audiometer at no cost.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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