|Year : 2015 | Volume
| Issue : 6 | Page : 734-738
Hearing loss in geriatric hemodialysis patients
Caner Sahin1, Ceyhun Varim2
1 ENT Clinic, Akyazi State Hospital, Sakarya, Turkey
2 Department of Internal Medicine, Sakarya University Training and Research Hospital, Sakarya, Turkey
|Date of Web Publication||19-Nov-2015|
Department of Internal Medicine, Sakarya University Training and Research Hospital, Sakarya
Source of Support: None, Conflict of Interest: None
Introduction: The aim of the study was to evaluate the hearing loss in geriatric hemodialysis patients. Materials and Methods: The study was performed on 16 geriatric hemodialysis patients (age minimum: 65, maximum: 86 years) and 16 volunteers (age minimum: 65, maximum: 86 years) as a control group. The patients' pure tone audiometry values between 250 and 8000 Hz frequencies were analyzed. Results: In our study, statistical significance was found between hearing loss and serum urea levels (P = 0.001). Hearing loss values were not statistically significantly different between the study and control groups (P = 0.786). High frequency hearing thresholds were found to be significantly higher in the geriatric hemodialysis patients (P = 0.032). Normal hearing levels at all levels were found in 5 patients in the study group. Mild to moderate hearing loss was found in 11 patients. Conclusions: In our preliminary study, we found statistically significant differences between the increase in hearing thresholds and uremia. Statistically significant changes in hearing thresholds at high frequencies were found between the two groups. Long-term hemodialysis treatment of 10 years or more is a risk factor for hearing loss. Hemodialysis treatment is a risk factor for hearing loss in geriatric patients who are at a risk of presbyacusis.
Keywords: Chronic renal insufficiency, hearing, renal dialysis
|How to cite this article:|
Sahin C, Varim C. Hearing loss in geriatric hemodialysis patients. Med J DY Patil Univ 2015;8:734-8
| Introduction|| |
Chronic renal failure (CRF) develops as a result of diseases such as diabetes mellitus (DM) and hypertension which progressively disrupts kidney function. Hemodialysis is a rearrangement of the liquid and the solute content of the body in patients with CRF.
Hearing loss may develop in geriatric hemodialysis patients. Late complications like hearing loss increase by year in geriatric hemodialysis patients. Prevalence of hearing loss varies between 20% and 75% in the patients receiving dialysis treatment in the literature.  Changes in blood pressure during hemodialysis, changes in osmotic pressure, ototoxic and nephrotoxic agents used in hemodialysis, and hemodialysis techniques play roles in the pathogenesis of hearing loss.  Hearing loss reduces the quality of life in hemodialysis patients.
We investigated the hearing loss in patients with CRF and the relationship between hearing loss, uremia, anemia, and duration of hemodialysis in the present study.
| Materials and Methods|| |
A total of 20 patients with CRF receiving hemodialysis treatment as a study group (Group 1) and 16 volunteers as a control group (Group 2) were included in this prospective study. The ages of both groups were minimum 65 years and maximum 86 years (mean age: 70 ± 6.1 years in Group 1 and 70 ± 4.8 in Group 2).
Seven patients had type 2 DM, 5 patients had hypertensive (HT), and 4 patients had both type 2 DM and HT diseases in the study group. Six patients had type 2 DM, 6 patients had HT, and 4 patients had both type 2 DM + HT in the control group. Patients in the control group have normal renal functions and are without ear diseases.
Patients using furosemide or other ototoxic and nephrotoxic drugs with chronic diseases except HT and DM, renal transplantation, myringosclerosis or tympanosclerosis in the eardrum, and chronic otitis media were excluded from the study. Two patients were excluded from the study because of chronic otitis media (2/20). One was excluded from the study because of using furosemide previously for a period of 2 years (1/20). Previous occupational noise exposure is asked and industrial workers/soldiers and potential occupational patients were excluded from the study. One patient (retired from professional army) was excluded from the study because of potential occupational risk (1/20). After exclusions, a total of 16 patients constituted study group. Control group is organized as a same number of the study group.
After 12-14 h of fasting, venous blood samples were obtained from subjects before hemodialysis for biochemical studies.
Patients in the study group were undergoing hemodialysis treatment with bicarbonate for 4 h/day, 3 times a week. During hemodialysis, 1000-5500 cc fluid per patient was withdrawn from the intravascular space by ultrafiltration. Na: 140 mmol/L, Ca: 1.5 mmol/L, and K: 2 mmol/L were used as dialysate and 1.5 m 2 polysulfone was used as a dialyzer.
Audiometric examination was performed in all groups. The Impedance Audiometer (AZ26, Interacoustics, Assens, Denmark) was used during the measurement. Patients' hearing thresholds were measured in the frequency of 250-500-1000-2000-4000-8000 Hz. Frequencies of 250-500 Hz were considered low frequencies; 1000-2000 Hz frequencies were considered medium frequencies; and 4000-8000 Hz were considered high frequencies. Patients with hearing loss were classified: 0-25 dB as normal, 26-40 dB as mild, 41-55 dB as moderate, 56-70 dB as moderate to severe, and 71-90 dB as severe hearing loss.  Acoustic reflexes and tympanometry of all patients were examined.
Written informed consent was obtained from each subject following a detailed explanation of the objectives and protocol of the study, which was conducted in accordance with the ethical principles stated in the declaration of Helsinki and approved by the institutional ethics committee.
Statistical analysis was made using computer software (SPSS version 15.0, SPSS Inc., Chicago, IL, USA). Hearing thresholds were calculated per frequency. An post-hoc Tukey's test was performed to determine the relationships between gender, hemoglobin, urea, and hearing thresholds. Data were expressed as mean (standard deviation) and P < 0.05 was considered statistically significant.
| Results|| |
Patients with CRF receiving hemodialysis treatment were determined as a study group (Group 1) and 16 volunteers were determined as a control group (Group 2) [Table 1] and [Table 2].
|Table 1: Demographic characteristics, HTD (year), and number of chronic disease-positive patients|
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Six cases of patients with hearing loss were female and 4 were male. Correlation was not found between hearing loss and gender (P = 1).
Urea values were measured as 120.5 ± 29.3 mg/dl and hemoglobin levels were measured as 11.7 ± 1.4 g/dl in the study group (the values were taken before hemodialysis treatment). Urea values were measured as 23.5 ± 5.8 mg/dl and hemoglobin levels were measured as 12.1 ± 3.1 g/dl in the control group [Table 1]. Correlation was not found between hearing loss and hemoglobin values (P = 0.659). Statistical significance was found between hearing loss and urea values (P < 0001).
Blood glucose values were measured as 139.4 ± 6.2 mg/dl and 135.2 ± 8.6 mg/dl. Statistically significant difference was not found in terms of hearing thresholds between groups with diabetic HT patients (P = 0.782).
Hearing loss levels were not found to be statistically significant between the study and control group (P = 0.675); however, there were differences in the configuration of hearing loss. High frequency hearing thresholds were found to be significantly higher in the study group (P = 0.03) [Figure 1]. The values of 8000 Hz for right ear were 48.7 ± 23 dB and 36.2 ± 14.2 for the left ear in the study group. The values of 8000 Hz for right ear were 48.7 ± 23 and 36.2 ± 18.5 for the left ear.
Duration of hemodialysis treatment is over 10 years for 4 patients in our study. Hearing loss was found in these 4 patients. Three of these patients had an intermediate hearing loss at the high frequencies. One patient had an intermediate hearing loss at the medium and high frequencies.
Normal hearing levels at all levels were found in 5 patients in the study group. Hearing loss was found in 11 patients.
Hearing loss at low frequencies was found in 5 of 11 in patients of the study group. One of these patients had mild hearing loss, 2 of these patients had moderate hearing loss, and 2 had moderate to severe losses [Table 3].
|Table 3: Hearing loss and degree according to frequencies of the study group|
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Hearing loss at medium frequencies was found in 4 of 11 patients in the study group. Two of these patients had moderate losses and 2 had moderate to severe losses [Table 3].
Hearing loss at high frequencies was found in 11 of 11 patients in the study group. Seven of these patients had a moderate loss and 4 of these patients had moderate to severe losses [Table 3].
Normal hearing levels at all levels were found in 7 patients in the control group. Hearing loss was found in 9 patients.
Hearing loss at low frequencies was found in 5 of 9 patients in the control group. One of these patients had mild hearing loss, 2 of these patients had moderate hearing loss, and 2 of these patients had moderate to severe losses [Table 4]. Hearing loss at medium frequencies was found in 5 of 9 in patients in the control group. Three of these patients had moderate hearing loss and 2 of these patients had moderate to severe losses [Table 4].
|Table 4: Hearing loss and degree according to frequencies of the control group|
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Hearing loss at high frequencies was found in 9 of 9 patients in the control group. One of these patients had mild hearing loss, 6 of these patients had moderate hearing loss, and 2 of these patients had moderate to severe losses [Table 4].
| Discussion|| |
Hearing loss may develop in hemodialysis patients  and reduce the quality of life in these patients. Development of hearing loss can be traced to cochlear activation along the line extending to the middle ear, and to the endolymphatic system and central metabolic changes.
The glomeruli and cochlear are similar structures to each other in terms of working principles of nerve impulses, active fluid transport, and electrolyte replacement. The gross structures are different even though similar at the cellular level.  Functional basal membrane/stria vascularis can be seen on the vascular support structure in both organs. There are drugs such as aminoglycosides and immunological diseases such as Alport syndrome that simultaneously affect both organs. 
Impairment in the organ of hearing may occur in patients with CRF. The prevalence of hearing loss is increasing in this group of disorders.  Diseases such as DM, hypertension, and hemodialysis treatment are risk factors for hearing loss.
Hemodialysis is a rearrangement of the liquid and the solute content of the body in patients with CRF. The purpose of hemodialysis treatment is to ensure proper fluid and solute exchange.  Acute hypotension, acute reduction in urea clearance, decrease in plasma osmotic pressure, and sudden increase in the number of red cells may develop during hemodialysis. Hypotension and the decrease in oncotic pressure during hemodialysis affect the cells by fluid and electrolyte replacement. 
Presbyacusis is defined as an age-related hearing loss. Reduction of hearing levels may occur with increasing age. In a study, the rate of admission to a doctor with hearing loss in the 65-74 age range was found to be 33%, in the 75-84 age range it was found to be 45%, and in over 85 age range it was found to be 62%.  Hearing loss observed in presbyacusis is symmetrical and bilateral, holding high frequencies at the beginning rather than radiating all frequencies.  The geriatric population in our study is a potential risk group in terms of hearing loss. Factors such as hemodialysis, uremia, HT, and DM are also risk factors for the hearing loss of these patients. In our study, the control group was selected from patients with HT and DM in order to equalize the risk groups. In our study, hearing thresholds at high frequencies in the study group were found to be significantly higher. This difference may be due to hemodialysis as well as possible multifactorial causes.
In the literature, it is stated that endolymphatic hydrops which may develop during hemodialysis may be one of the causes of vertigo in patients.  Rapid removal of urea from the serum during hemodialysis causes a rapid decrease in the serum osmolarity. As a result, edema occurs in stria vascularis, hair cells, and also in supporting cells. At the same time, a liquid stream develops toward vascular space to the perilymph. Studies investigating the effect of hemodialysis on otoacoustic emissions are featured in the literature. No significant changes were found in emissions after hemodialysis. , None of our patients was diagnosed with Ménière's syndrome in our study.
Bazzi et al. found that hearing loss was higher in the patients undergoing hemodialysis treatment for over 10 years.  In our study, 4 patients has been undergoing hemodialysis for 10 years or more, and all of these patients had severe or less severe hearing loss. In this respect, patients receiving hemodialysis for a long time are at a risk for hearing loss.
There are studies showing the effect of hemodialysis, otoacoustic emissions, and brain stem on the hearing in the literature.  Serbetçioglu et al. did not detect changes in the threshold values of pre- and post-dialysis. , There is no consensus in the literature on this topic. Ozturan and Lam found that CRF may cause hearing loss by determining otoacoustic emissions.  In our study, a significant difference was found between uremia and hearing loss.
| Conclusion|| |
We found statistically significant differences between the increase in hearing thresholds and uremia. Long-term hemodialysis treatment of 10 years or more is a risk factor for hearing loss. Hemodialysis treatment is a risk factor for hearing loss in geriatric patients who are at risk of presbyacusis. Our study is a preliminary study with a small number of cases. We tried to investigate the relationship between hemodialysis and hearing loss because of the quality of life issue. This is a disadvantage for our study. Further, larger series of the issue has to be done to investigate the issue. More objective tests such as otoacoustic emission and ABR will provide further valuable information about the issue. Further investigations including postmortem studies need to be done to investigate the issue.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]