Download THE COMPARISON OF DIALYSIS TYPES` EFFECTS ON HEARING

THE COMPARISON OF DIALYSIS TYPES’ EFFECTS ON HEARING
ACUITY AND BAER FINDINGS IN PATIENTS WITH CHRONIC RENAL
FAILURE
Assist. Prof. Sebahattin CÜREOĞLU, MD*
Assist. Prof. Üstün OSMA, MD*
Research Fellow Zafer ALKAYA, MD*
Research Fellow Yasin SARI, MD**
Assoc. Prof. Faruk MERIÇ, MD*
Prof. İsmail TOPÇU, MD*
Assoc. Prof. M.Emin YILMAZ**
*Dicle University, School of Medicine, Department of Otorhinolaryngology
** Dicle University, School of Medicine, Department of Nephrology
Running Title: Effect of dialysis on hearing in renal failure
Key words: Chronic renal failure, hearing loss, hemodialysis, peritoneal dialysis, BAER
Corresponding Address: Yrd. Doç. Dr. Sebahattin CÜREOĞLU
Dicle Ün.Tıp Fak. KBB Anabilim Dalı, 21280, Diyarbakır- TURKEY
E-Mail: [email protected]
Total number of pages: 11
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Abbreviations used:
CRF, chronic renal failure;
PTA, pure-tone audiometry;
TTD, Threshold tone decay test;
BAER, Brainstem auditory evoked;
SNHL, sensorineural hearing loss.
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THE COMPARISON OF DIALYSIS TYPES’ EFFECTS ON HEARING
ACUITY AND BAER FINDINGS IN PATIENTS WİTH CHRONIC RENAL
FAILURE
Abstract
In this study, the origin of hearing loss in patients with chronic renal failure (CRF)
and the effect of dialysis type on hearing loss due to CRF was investigated. For
these purposes, 40 patients with CRF ( 20 in hemodialysis and 20 in peritoneal
dialysis program) were examined for hearing acuity by pure-tone audiometry (PTA),
Threshold tone decay (TTD) test and Brainstem auditory evoked response (BAER).
The hearing loss (13 cochlear, 10 retrocochlear in TTD test), was found in 57.5 % of
patients. BAER findings showed that III., V. absolute latencies and I-III., III-V
interpeak latencies were significantly longer in hemodialysis group than control
group. No statistical significance was found between hemodialysis and peritoneal
dialysis groups in audiological and BAER findings. Significant changes were not
also observed before and after hemodialysis. It is concluded that both cochlea and
retrocochlear region are susceptible to the effect of uremia. The type of dialysis has
not affected the degree of hearing loss in CRF patients.
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Introduction
Etiology of sensorineural hearing loss (SNHL) seen in CRF patients is
contradictory. In the literature, uremic toxins, anemia, electrolyte imbalance,
chelating agents used in hemodialysis, ototoxic medications, metabolic imbalances,
immune deficiencies, dialysis type, and dialysis frequency were shown responsible
for SNHL (1-4). The purpose of this investigation was to evaluate auditory ability
and brainstem auditory evoked response (BAER) findings of CRF patients who were
treated by dialysis and also the effect of dialysis type on hearing acuity.
Patients and methods
This study included 40 patients with CRF who were on dialysis medication.The
diagnosis of a CRF was based on history, physical examination, laboratory tests, and
biopsy study. Since the patients could no longer be maintained conservatively by
medication and diet, they were treated by dialysis. Three groups were included in the
study; Group I, 20 patients (13 males, 7 females) with CRF taking hemodialysis (14
patients were taking dialysis 3 times a week, 6 patients were taking twice a week);
Group II, 20 patients (12 males, 8 females) taking peritoneal dialysis (patients were
taking dialysis twice a day); Group III, 20 persons (13 males, 7 females) as control.
Patient with a family history of hearing loss, chronic otitis media, ototoxic
medication, acoustic trauma and diabetes mellitus, and patients who were over 40
years old to eliminate presbyacusis were excluded from the study. All patients had
otoscopic examination before tests to exclude external factors. BUN, creatinin,
electrolytes and glucose levels were measured before dialysis. Pure tone audiometry,
Threshold tone decay (TTD) test, and 80 dBHL BAER potentials were recorded
before and after dialysis. Our standard isolated audiology laboratory was used for
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tonal, supraliminary test and BAER. 2048 rarefaction click in 10srr/sec were used in
BAER. We used Medelec Sapphire 2A equipment for BAER, Madsen OB-822 for
audiometry, Amplaid 720 for tympanometry. We considered 250-500,1000 Hz
hearing levels as low frequency levels, 2000, 4000, 6000, 8000 Hz levels as high
frequency hearing levels. The findings were compared among hemodialysis group,
peritoneal dialysis group, and control group. 25 dBHL was accepted normal
according to the ISO-1964 standards. In statistical evaluation, ANOVA test and Post
hoc Tukey procedure were used to understand which groups are different.
Results
The mean age of patients was 31,7 (range 17-40 years) in patient’s group, 32.5 in
control group. Etiology of CRF in these patients is shown in Table 1. Mean patients’
diseased period was 4 years (1-18) in both peritoneal dialysis and hemodialysis
groups. On the basis of test results; in hemodialysis group, (6 patients had cochlear,
and 5 had retrocochlear) totally 11 had SNHL. In peritoneal dialysis group, (7
patients had cochlear, 5 had retrocochlear), totally 12 had SNHL. Hearing loss
mostly were in high frequencies. TTD test showed cochlear pathology in 13 patients
and retrocochlear pathology in 10 patients. Significant prolongation of I. absolute
latency in cochlear group was observed when the BAER results of cochlear and
retrocochlear groups were compared (p<0.05). Hearing levels in controls were
12.65-/+ 5.64 in low frequencies, and 16.52 -/+ 4.74 in high frequencies. Hearing
levels were 20.40 -/+ 13.1 and 31.1-/+ 17.5 in peritoneal dialysis group, and 20.90-/+
14.1 and 35.0-/+19.0 in hemodialysis group accordingly. There was significant
difference in hearing levels between patient’s and control’s group (P<0.01). There
was no significant difference in audiometrical findings between hemodialysis and
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peritoneal dialysis group. There was no significant difference in high frequency and
low frequency hearing levels before and after hemodialysis. BAER results are given
in Table 2. As seen in Table 2, there was significant difference for III., V. absolute
and I-III, III-V interpeak latencies between hemodialysis and control groups. But
there was no significant difference among the BAER results of hemodialysis (before
and after), and peritoneal dialysis groups.
Discussion
After the first reported hearing loss in patients with CRF by Diafaley, some
authors reported varying degrees of hearing loss (1-8). In our study, hearing loss was
found in 23 (57.5%) patients. Patients with CRF have usually high frequency hearing
loss 1,6. But Gatland et al. also reported both high and low frequency losses(3). In our
study, most of them had high frequency loss, but we also detected low frequency
component of hearing loss in patients.
The causes and the origin of hearing loss are contradictory. Yassin et al. has
proposed a possible common defect in the electrolyte transport through membranes
and that hearing loss was correlated with hyponatremia(9). But Kopsa et al. found no
correlation between them(4). In our study groups, serum Na, K and Ca levels were
normal. It was suggested that when diuretics and aminoglycosides are used together,
they may effect stria vascularis and corti organ and cause ototoxicity(10). But none
of our patients had used them so we discluded their effect. Because metabolic disease
like diabetes mellitus may effect cochlear blood supply, we didn’t take this group to
our study.
Some authors demonstrated the involvement of both central and peripheral nervous
systems, which was already present before hemodialysis and thought that it was
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possibly due to ureamic neuropathy(11,12). It is reported that the effect of uremia to
stria vascularis causes cochlear hearing loss(13). Wigand et al. reported an average
hearing loss of 20 dB in a group of ureamic patients, particularly in the higher
frequencies, suggesting cochlear involvement(14). The study by Marsh suggests that
the acoustic nerve more vulnerable to the effects of uremia(15). Retrocochlear
hearing loss is considered to be the result of demyelinization from superior olivary
nucleus to inferior colliculus(16,17). But demyelinization in cochleovestibular
preganglioner fibers also contributes to retrocochlear hearing loss(17). Our results
have shown both cochlear and retrocochlear hearing loss, and 13 patients had
cochlear and 10 had retrocochlear pathology according to the TTD test. They also
had prolonged absolute III., V. latencies and prolonged I-III, III-V interpeak
latencies. Significant prolongation of I. absolute latency in cochlear group was
observed when the BAER results of cochlear and retrocochlear groups were
compared.
Some authors reported that hearing loss got better after dialysis(3,8), but there are
some reports showing worsening of hearing(2,7,18). It was shown that prolonged
first-wave latency was reported in hemodialysis patients in one study(15), whereas
the fifth wave latency was prolonged in another study(19). Gafter et al. showed
prolongation of III and V waves latencies in patients with CRF(12). The results of
prolonged BAER latencies are in accordance with previous studies which showed
delayed prolongation mostly of the later waves III, V and interpeak III-V latency in
patients on hemodialysis(12,19). Bazzi et al. did not find any significant differences
in the frequency and severity of hypoacousia in the groups with different durations of
dialysis(20). Mirahmadi et al. did not find evidence of any worsening of hearing after
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regular dialysis treatment protracted for 1-5 years(21). Oda et al. has proposed that
long term hemodialysis treatment may cause electrolyte, osmotic, and biochemical
alterations leading to SNHL(22). In our study, there was no significant difference
between pre and post dialysis audiometrical and BAER findings. It was suggested
that hemodialysis has caused more hearing deficiency in compare with peritoneal
dialysis(2). In our study, hemodialysis group has lower hearing levels in compare
with peritoneal dialysis group but it was not significant statistically.
By looking at our results, we concluded that there was no difference between
hemodialysis and peritoneal dialysis in effecting hearing. BAER findings exhibit no
improvement of neural conduction after hemodialysis in patients with CRF. The
present study may also suggest that cochlea and retrocochlear region especially the
pons and midbrain is more susceptible to the effect of uremia.
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Table 1. Etiological factors in patients with CRF.
Etiology
Case number (n=40)
Chronic Pyelonephritis + nephrolithiasis
15
Chronic Glomerulonephritis
10
Amiloidosis
Unknown
3
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Table 2. Absolute and interpeak latencies of BAER waves in hemodialysis, Peritoneal
dialysis groups and controls .
Group
I
III
V
I-III
Control
1.68
3.80
5.76
2.11
1.96
4.07
Hemodialysis
1.73
3.99
5.97
2.22
1.99
4.22
Peritoneal dialysis 1.70
3.93
5.88
2.20
1.95
4.16
P
<0.05* <0.05*
>0.05
<0.05*
III-V
<0.05*
I-V (msn)
>0.05
*The difference is found between hemodialysis and control groups.
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