Abstract
Introduction Hearing is a complex process that involves mechanical, chemical, and neurophysiological components. Changes in hearing can be caused by congenital or acquired etiological factors. Chronic kidney disease (CKD) is one of the causes of hearing loss.
Objective To compare auditory findings before and after a single session of hemodialysis in patients with chronic kidney disease.
Methods A clinical cross-sectional research was conducted with a sample of 23 individuals between 24 to 57 years of age with a diagnosis of CKD undergoing hemodialysis. Distortion product otoacoustic emission (DPOAE) and transient otoacoustic emission (TOAE) tests were performed before and after a session of hemodialysis.
Results The DPOAE test revealed that 26% of the participants had failure in both ears prior to dialysis and 30.4% had failure after dialysis. Comparing the DPOAE and TOAE tests before and after hemodialysis, a slight decrease was found in patients with “fail” results from the predialysis test to the postdialysis test, but the difference did not achieve statistical significance.
Conclusions No significant hearing changes assessed through otoacoustic emissions occurred after a single session of hemodialysis in the sample analyzed.
Keywords: hemodialysis, hearing tests, hearing loss
Introduction
Hearing is a complex process that involves mechanical, chemical, and neurophysiological components. Changes in hearing can be caused by congenital or acquired etiological factors, with various degrees and types of hearing loss. One possible cause is chronic kidney disease (CKD). Studies report that the prevalence of neurosensory hearing loss among patients with CKD ranges from 28 to 77%, 1 2 which is considerably higher than the rate found in the general population.
Although the association between CKD and hearing loss has been reported, the physiopathological mechanics of this condition have not been investigated. 3 4 5 The kidneys and cochlea are similar in regard to both structure and physiological mechanisms, involving the transport of fluids and electrolytes, which may explain hearing loss in individuals with CKD. 6 7
Other causes of hearing loss in this population have been considered, such as factors related to the severity and duration of CKD, electrolyte disorders, the use of ototoxic drugs, advanced age, comorbidities (diabetes mellitus and hypertension), and hemodialysis. 1 8 9
The systematic frequency of hemodialysis sessions can induce electrolytic, biochemical, immunological, osmotic, and vascular changes that can alter the functioning of the inner ear. 10 Therefore, the aim of the present study was to compare the auditory findings of patients diagnosed with CKD before and after a single session of hemodialysis.
Methods
The present clinical cross-sectional study received approval from the Human Research Ethics Committee (approval number: 123.444) and was conducted in compliance with Resolution 466/2012 of the National Board of Health. All volunteers agreed to participate by signing a statement of informed consent.
Data collection took place between June 2022 and March 2023. Auditory findings were obtained before and after a single session of hemodialysis in patients with a diagnosis of CKD using distortion product otoacoustic emission (DPOAE) and transient otoacoustic emission (TOAE) tests with the aid of the Ero-Scan Pro (MAICO Diagnostics, Eden Prairie, MN, USA), duly calibrated following the ANSI S3.6 standard.
Twenty-three adults with CKD undergoing hemodialysis, irrespective of the time elapsed since diagnosis, were included. The exclusion criteria were age older than 60 years, individuals with altered hearing prior to the diagnosis of CKD, a history of exposure to noises of strong intensity, a family history of deafness, history of infection by rubella, cytomegalovirus, syphilis, herpes, hepatitis B, hepatitis C, or human immunodeficiency virus (HIV), individuals having undergone or currently undergoing treatment for cancer, and individuals having received a kidney transplant.
The otoacoustic emission (OAE) tests were performed by the same speech therapist in a silent room prior to and immediately after the end of the hemodialysis session. The following procedures were employed:
- Test in QuickScreen mode (rapid format with 12 milliseconds analysis window).
- Global analysis of responses for both TOAE and DPOAE, using the pass/fail protocol.
- Transient otoacoustic emission measured at frequencies of 1.5, 2.0, 2.5, 3.0, 3.5, and 4.0 KHz through 83 dB NPS click stimulus (duration ∼ 64 seconds). To be considered present, the signal/noise ratio (SNR) needed to be ≥ 6 dB at frequences between 1.0 and 4.0 KHz, and responses for at least 3 frequencies were required.
- Distortion product otoacoustic emission measured using 2 simultaneous pure tones with different frequencies at intensities P1 = 65 dB NPS and P2 = 55 dB NPS at frequencies of 2.0, 3.0, 4.0, and 5.0 KHz. Distortion product otoacoustic emission analyses were performed per frequency with the following criteria: amplitude (SD) greater than −5 dB and SNR higher than 6 dB.
The data were expressed as absolute and relative (%) frequencies. The Student t -test for paired samples was used to determine differences in the results before and after hemodialysis. The Chi-squared test was used to test possible associations with a 95% confidence interval (CI). The significance level was set at 5% ( p < 0.05). All analyses were performed with the aid of the SPSS Statistics for Windows, version 13.0 (SPSS Inc., Chicago, IL, USA).
Results
A total of 30 patients were recruited, three of whom met one or more exclusion criteria and four who did not return for the follow-up exam after hemodialysis. Thus, the final sample comprised 23 individuals—12 women (52.1%) and 11 men (47.8%). Patient's ages ranged from 24 to 57 years, with a mean and standard deviation of 41 ± 9.82 years. The average duration of hemodialysis was 9.17 years (range: 1–36 years). With regards to comorbidities, 4 patients (17.3%) had diabetes mellitus and 17 (73.9%) had arterial hypertension. All patients had 3-weekly sessions of hemodialysis, with an average of four hours per session ( Table 1 ).
Table 1. Demographic and clinical characteristics of sample ( n = 23) .
| Variables | Female n (%) |
Male n (%) |
Total n (%) |
|---|---|---|---|
| Demographic | |||
| Age group (years) | |||
| 24–30 | 3 (13.0) | 1 (4.34) | 4 (17.3) |
| 31–40 | 4 (17.3) | 3 (13.0) | 7 (30.4) |
| 41–50 | 5 (21.7) | 3 (13.0) | 8 (34.7) |
| 51–57 | 0 (0.0) | 4 (17.3) | 4 (17.3) |
| Clinical | |||
| Duration of dialysis (years) | |||
| 1–10 | 9 (39.1) | 7 (30.4) | 16 (69.5) |
| 11–20 | 1 (4.34) | 2 (8.6) | 3 (13.0) |
| 21–30 | 1 (4.34) | 2 (8.6) | 3 (13.0) |
| 31–40 | 1 (4.34) | 0 (0.0) | 1 (4.34) |
| Diabetes | |||
| Yes | 3 (13.0) | 1 (4.34) | 4 (17.3) |
| No | 9 (39.1) | 10 (43.4) | 19 (82.6) |
| Hypertension | |||
| Yes | 10 (43.4) | 7 (30.4) | 17 |
| No | 2 (8.6) | 4 (17.3) | 6 |
| Auditory symptoms | |||
| Tinnitus | 3 (13.0) | 4 (17.3) | 7 (30.4) |
| Hearing loss | 2 (8.6) | 3 (13.0) | 5 (21.7) |
| Total | 12 (52.1) | 11 (47.8) | 23 (100) |
Source: Author, 2023.
There were 7 patients (30.4%) with complaints of tinnitus, 6 of whom (26.0%) described the frequency of the symptom as sporadic, occurring mainly at the end of the hemodialysis session and characterized as mild. Also, 5 patients (21.7%) reported hearing loss, and 100% had no knowledge of hearing impairment being linked to kidney disease.
Furthermore, 6 patients (26.0%) failed in both ears during the predialysis DPOAE test, and 5 (21.7%) failed during the postdialysis test. There were 7 patients (30.4%) who failed during the predialysis TOAE test, and 7 (30.4%) failed during the postdialysis test ( Table 2 ). In the analysis of patients who “passed” or “failed” in both ears on the DPOAE and TOAE tests, no associations were found with age group or duration of hemodialysis.
Table 2. General responses on pre and postdialysis OAE tests using pass/fail system.
| GENERAL OAE RESPONSES | ||||||||
|---|---|---|---|---|---|---|---|---|
| DPOAE n = 23 | TOAE n = 23 | |||||||
| Side | Pre-dialysis | Post-dialysis | Pre-dialysis | Post-dialysis | ||||
| Pass n % |
Fail n % |
Pass n % |
Fail n % |
Pass n % |
Fail n % |
Pass n % |
Fail n % |
|
| BEs | 13 (56.5) | 6 (26.0) | 12 (52.1) | 5 (21.7) | 10 (43.4) | 7 (30.4) | 13 (56.5) | 7 (30.4) |
| RE | 14 (60.8) | 9 (39.1) | 16 (69.5) | 7 (30.4) | 13 (56.5) | 10 (43.4) | 16 (69.5) | 7 (30.4) |
| LE | 17 (73.9) | 6 (26.0) | 14 (60.8) | 9 (39.1) | 13 (56.5) | 10 (43.4) | 13 (56.5) | 10 (43.4) |
Abbreviations: BEs, both ears; DPOAE, distortion product otoacoustic emission; LE, left ear; RE, right ear; TOAE, transient otoacoustic emission; OAE, otoacoustic emission.
A greater number of failures were found for TOAE in both the right and left ears compared with DPOAE. Failures were predominantly in the left ear for DPOAE in the postdialysis test and in the left ear for TOAE in both the pre and postdialysis tests.
In the analysis of the frequencies tested, a greater number of patients failed at the highest frequencies (4.0 and 5.0 KHz) on both the pre and postdialysis tests ( Table 3 ). A discrete reduction was found in the number of patients who failed at all frequencies in the right ear between the pre and postdialysis tests. In contrast, an increase was found in the number of patients who failed at all frequencies in the left ear between the pre and postdialysis tests. However, the Student t -test revealed that the differences did not achieve statistical significance ( p > 0.05).
Table 3. Distribution of pre and postdialysis results (pass/fail) of DPOAE by ear ( n = 23) .
| Frequency (KHz) |
Fail RE |
Fail LE |
||
|---|---|---|---|---|
| Pre (%) | Post (%) | Pre (%) | Post (%) | |
| 2.0 | 5 (21.7) | 4 (17.3) | 1 (4.34) | 5 (21.7) |
| 3.0 | 6 (26.0) | 4 (17.3) | 7 (30.4) | 8 (34.7) |
| 4.0 | 10 (43.4) | 9 (39.1) | 9 (39.1) | 10 (43.4) |
| 5.0 | 10 (43.4) | 9 (39.1) | 6 (26.0) | 7 (30.4) |
Abbreviations: DPOAE, distortion product otoacoustic emission; LE, left ear; RE, right ear.
Note: Student t -test p > 0.05.
The results of the TOAE analysis for the number of patients who failed at each frequency are displayed in Table 4 . A greater number of patients failed at frequencies of 3.0, 3.5, and 4.0 KHz for both the right and left ears. In the comparison of the pre and postdialysis tests, an increase was found in the number of patients who failed at frequencies of 1.5 and 4.0 KHz for the right ear and frequencies of 2.5 and 3.5 KHz for the left ear. The results also show a reduction in the number of patients who failed on the postdialysis tests at frequencies of 2.0, 3.0, 3.5, and 4.0 KHz for the right ear and frequencies of 1.5, 2.0, and 4.0 KHz for the left ear. However, no statistically significant differences were found in the comparison of the pre and postdialysis tests ( p > 0.05).
Table 4. Distribution of pre and postdialysis results (pass/fail) of TOAE by ear ( n = 23) .
| Frequency (KHz) |
Fail RE |
Fail LE |
||
|---|---|---|---|---|
| Pre (%) | Post (%) | Pre (%) | Post (%) | |
| 1.5 | 8 (34.7) | 10 (43.4) | 11 (47.8) | 7 (30.4) |
| 2.0 | 10 (43.4) | 8 (34.7) | 10 (43.4) | 8 (34.7) |
| 2.5 | 11 (47.8) | 11 (47.8) | 12 (52.1) | 14 (60.8) |
| 3.0 | 16 (69.5) | 13 (56.5) | 15 (65.2) | 15 (65.2) |
| 3.5 | 15 (65.2) | 13 (56.5) | 16 (69.5) | 19 (82.6) |
| 4.0 | 19 (82.6) | 12 (52.1) | 12 (52.1) | 10 (43.4) |
Abbreviations: LE, left ear; RE, right ear; TOAE, transient otoacoustic emission.
Note: Student t -test p > 0.05.
An increase was found in the responses of the mean S/N ratio at all frequencies tested for the right ear and a frequency of 3.0 KHz for the left ear between the pre and postdialysis DPOAE tests ( Table 5 ).
Table 5. Mean signal/noise ratios of DPOAE ( n = 23) .
| S/N ratio | 2.0 | 3.0 | 4.0 | 5.0 | ||||
|---|---|---|---|---|---|---|---|---|
| RE | Pre | Post | Pre | Post | Pre | Post | Pre | Post |
| Mean | 12.2 | 16 | 15.8 | 16 | 15.4 | 16.1 | 16.7 | 17.2 |
| SD | 10 | 8.7 | 8.7 | 8.2 | 9.5 | 9.0 | 11.1 | 9.3 |
| Minimum | −10.3 | −3 | −2.9 | −3 | 0 | 0.1 | −6 | −1 |
| Maximum | 30.2 | 30.5 | 31.7 | 29.3 | 32.2 | 31.2 | 32.9 | 31 |
| LE | ||||||||
| Mean | 15 | 13 | 16 | 16.2 | 17.3 | 15 | 18.8 | 17 |
| SD | 8.7 | 8.7 | 9.3 | 7.2 | 10 | 10.2 | 9.3 | 9.2 |
| Minimum | 2 | 0 | −1 | 0 | −4 | −1 | −1.1 | −1 |
| Maximum | 34.2 | 30.6 | 30.1 | 26.3 | 30.2 | 29.6 | 27 | 28.3 |
Abbreviations: DPOAE, distortion product otoacoustic emission; LE, left ear; RE, right ear; SD, standard deviation.
Source: Author, 2023.
In the analysis of mean SNR for pre and postdialysis TOAE, an increase in values was found at frequencies of 2.5, 3.0, and 3.5 KHz for the right ear and frequencies of 1.5, 2.0, 2.5, and 3.0 KHz for the left ear ( Table 6 ).
Table 6. Mean signal/noise ratios of TOAE ( n = 12) .
| S/N ratio | 1.5 | 2.0 | 2.5 | 3.0 | 3.5 | 4.0 | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| RE | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post |
| Mean | 12.4 | 5 | 9.6 | 5 | −5.4 | 5 | −1.4 | 4.6 | 1.1 | 4 | 4.4 | 3 |
| SD | 7.5 | 6.3 | 4.8 | 4.2 | 6.7 | 4.9 | 5.6 | 5.5 | 3.2 | 5.1 | 2.9 | 4.5 |
| Minimum | −7 | −3 | −2 | −2.1 | −6 | −3.3 | −10 | −48 | −5 | −8.1 | −4 | −3.8 |
| Maximum | 15.8 | 19.8 | 13.6 | 13.6 | 13 | 14.7 | 15 | 15 | 11.5 | 12 | 7 | 13.2 |
| LE | ||||||||||||
| Mean | 4.9 | 7 | 4 | 5 | 2.4 | 6 | 3.8 | 4 | 3.9 | 2 | 6 | 5.7 |
| SD | 4.9 | 4 | 4.6 | 4.6 | 5.8 | 4.8 | 3.8 | 4.5 | 4.3 | 3.9 | 4.9 | 4.9 |
| Minimum | −3 | −1 | −3 | −3 | −6 | −3 | −12 | −6 | −5 | 3.5 | −4.6 | −3.5 |
| Maximum | 19.6 | 16.1 | 15.4 | 15.4 | 14.5 | 16.4 | 12.7 | 12.7 | 12.2 | 12.2 | 13 | 13 |
Abbreviations: LE, left ear; RE, right ear; SD, standard deviation; TOAE, transient otoacoustic emission.
Source: Author, 2023.
Discussion
The hearing of patients with CKD has been widely studied in different countries in recent years, with important results demonstrating the risk of hearing loss in this population. 11 12 13 14 15 16 The most common finding is bilateral neurosensory hearing loss, with higher frequencies affected more and a notch at 6 KHz. 17
Similar results were found in the present study, as a larger number of patients failed at the frequencies of 4.0 and 5.0 KHz for DPOAE and frequencies of 3.0, 3.5, and 4.0 KHz for TOAE. The sample was composed of 12 women and 11 men, and no significant associations were found with sex, age group, or duration of hemodialysis.
The authors of a case-control study also identified neurosensory hearing loss in a sample of 50 patients with CKD and found no associations between hearing loss and disease duration or age. 14 However, Wu et al. 18 found that the risk of hearing loss increased considerably with the duration of the disease.
The type of treatment and its relationship to hearing loss is another point widely discussed in the literature. Patients on hemodialysis have better hearing results compared with those undergoing conservative treatment (medicinal therapy). 12
Although no statistically significant differences were found between the OETs conducted before and after hemodialysis, a discrete reduction was found in the number of patients who failed on the postdialysis tests. In 2001, Şerbetçioğlu et al. 19 studied 19 adults submitted to the high-frequency tonal audiometric test 1 hour before and 2 hours after hemodialysis and found no significant effect on hearing after a single session.
It is noteworthy that OAE tests have greater specificity for the assessment of cochlear function than other exams. These tests enable identifying cochlear disfunction prior to the change in audiometry. 20 21 22 Ozturan and Lam 23 also used OAE tests before and after a single session of hemodialysis and found no effect on hearing.
The reduction in the number of patients who failed the postdialysis test in the present investigation has been reported in previous studies. 24 Hemodialysis corrects a large part of hydroelectrical and metabolic changes of the endolymph induced by CKD and promotes the stabilization and correction of metabolic changes caused by the disease, leading to an increase in neural conduction and restoring the function of ciliated cells. 1 25 According to Gafter et al., 26 dialysis may be beneficial to hearing, but the effect is temporary.
Although numerous studies have associated hearing loss and CKD, few investigated the symptom of tinnitus. This symptom is defined as consciously perceptible sound in the absence of an external auditory stimulus. 27 Like hearing loss, tinnitus has a negative impact on quality of life. 28 In a retrospective cohort study involving 185,430 patients with CKD, Shih et al. 29 concluded that the disease constitutes a significant, independent risk factor for tinnitus and that patients with terminal kidney disease on dialysis are at greater risk of tinnitus than patients with CKD not undergoing dialysis.
In the present study, 30.4% of the patients reported tinnitus as an auditory symptom. The etiology of tinnitus can be considered multifactorial. Patients with arterial hypertension, diabetes mellitus, heart failure, and liver cirrhosis are at greater risk of tinnitus, and many of these factors are commonly found in individuals with CKD.
Conclusions
No statistically significant auditory changes were found after a single session of hemodialysis in the sample analyzed. However, the number of patients who failed on the DPOAE and TOAE responses diminished following hemodialysis, characterizing an improvement in hearing.
Funding Statement
Funding
Footnotes
Conflict of Interests The authors have no conflict of interests to declare.
References
- 1.Saeed H K, Al-Abbasi A M, Al-Maliki S K, Al-Asadi J N. Sensorineural hearing loss in patients with chronic renal failure on hemodialysis in Basrah, Iraq. Tzu-Chi Med J. 2018;30(04):216–220. doi: 10.4103/tcmj.tcmj_149_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kim S, Lee D K, Kim H R, Park J M, Kim S B, Yu H. Treatment outcomes for idiopathic sudden sensorineural hearing loss in dialysis patients. Sci Rep. 2024;14(01):360. doi: 10.1038/s41598-023-49306-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.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(10):587–589. doi: 10.1177/014107689108401006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Pirodda A, Ferri G G, Raimondi M C, Borghi C.Kidney disease and inner ear sufferance of non-familial origin: A review of the literature and a proposal of explanation. Vol. 8J Int Adv Otol2012
- 5.Kumar K A, Hishamudin A DB, Krishnan D A et al. The effect of hemodialysis on hearing in chronic kidney disease patients – A systematic review. Indian J Med Sci. 2022;74(01):32–39. [Google Scholar]
- 6.Fufore M B, Kirfi A M, Salisu A D, Samdi T M, Abubakar A B, Onakoya P A. Stage of chronic kidney disease and cochlear function: A cross-sectional survey. Niger Postgrad Med J. 2020;27(02):122–126. doi: 10.4103/npmj.npmj_148_19. [DOI] [PubMed] [Google Scholar]
- 7.Liu W, Meng Q, Wang Y et al. The association between reduced kidney function and hearing loss: a cross-sectional study. BMC Nephrol. 2020;21(01):145. doi: 10.1186/s12882-020-01810-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Renda R, Renda L, Selçuk ÖT, Eyigör H, Yılmaz M D, Osma Ü. Cochlear sensitivity in children with chronic kidney disease and end-stage renal disease undergoing hemodialysis. Int J Pediatr Otorhinolaryngol. 2015;79(12):2378–2383. doi: 10.1016/j.ijporl.2015.10.048. [DOI] [PubMed] [Google Scholar]
- 9.Greenberg D, Rosenblum N D, Tonelli M. The multifaceted links between hearing loss and chronic kidney disease. Nat Rev Nephrol. 2024;20(05):295–312. doi: 10.1038/s41581-024-00808-2. [DOI] [PubMed] [Google Scholar]
- 10.Reddy E K, Surya Prakash D R, Rama Krishna M GKD.Proportion of hearing loss in chronic renal failure: Our experienceIndian Journal of Otology. 2016;22(01):
- 11.Peyvandi A, Roozbahany N A. Hearing loss in chronic renal failure patient undergoing hemodialysis. Indian J Otolaryngol Head Neck Surg. 2013;65 03:537–540. doi: 10.1007/s12070-011-0454-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Sam S KT.Hearing impairment in patients with Chronic Renal FailureJournal of Medical Science And Clinical Research. 2014;2(02):
- 13.Seo Y J, Ko S B, Ha T H et al. Association of hearing impairment with chronic kidney disease: a cross-sectional study of the Korean general population. BMC Nephrol. 2015;16(01):154. doi: 10.1186/s12882-015-0151-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Boateng J O, Boafo N, Osafo C, Anim-Sampong S. Hearing impairment among chronic kidney disease patients on haemodialysis at a tertiary hospital in Ghana. Ghana Med J. 2019;53(03):197–203. doi: 10.4314/gmj.v53i3.3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Gupta S, Curhan S G, Cruickshanks K J, Klein B EK, Klein R, Curhan G C. Chronic kidney disease and the risk of incident hearing loss. Laryngoscope. 2020;130(04):E213–E219. doi: 10.1002/lary.28088. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Fadel F I, Yamamah G AN, Hasanin R M et al. Hearing assessment in Egyptian children with chronic renal failure on regular hemodialysis and renal transplantation children. Ther Apher Dial. 2022;26(05):960–968. doi: 10.1111/1744-9987.13783. [DOI] [PubMed] [Google Scholar]
- 17.Agrawal M, Singh C V. Sensorineural Hearing Loss in Patients With Chronic Kidney Disease: A Comprehensive Review. Cureus. 2023;15(11):e48244. doi: 10.7759/cureus.48244. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Wu K L, Shih C P, Chan J S et al. Investigation of the relationship between sensorineural hearing loss and associated comorbidities in patients with chronic kidney disease: A nationwide, population-based cohort study. PLoS One. 2020;15(09):e0238913. doi: 10.1371/journal.pone.0238913. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Serbetçioğlu M B, Erdoğan S, Sifil A. Effects of a single session of hemodialysis on hearing abilities. Acta Otolaryngol. 2001;121(07):836–838. doi: 10.1080/00016480152602294. [DOI] [PubMed] [Google Scholar]
- 20.Yilmaz S, Öktem F, Karaman E. Detection of cisplatin-induced ototoxicity with transient evoked otoacoustic emission test before pure tone audiometer. Eur Arch Otorhinolaryngol. 2010;267(07):1041–1044. doi: 10.1007/s00405-009-1165-7. [DOI] [PubMed] [Google Scholar]
- 21.Sharifian M R, Kamandi S, Sima H R, Zaringhalam M A, Bakhshaee M. INF- α and ototoxicity. BioMed Res Int. 2013;2013:295327. doi: 10.1155/2013/295327. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Corvaro C, Lagreca L CC, Munhoz M SL, de Azevedo M F. Emissões otoacústicas evocadas na doença de Ménière. Audiol Commun Res. 2022;•••:27. [Google Scholar]
- 23.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(06):306–313. doi: 10.1159/000027615. [DOI] [PubMed] [Google Scholar]
- 24.Aspris A K, Thodi C D, Balatsouras D G, Thodis E D, Vargemezis V, Danielides V. Auditory brainstem responses in patients under treatment of hemodialysis. Ren Fail. 2008;30(04):383–390. doi: 10.1080/08860220801947405. [DOI] [PubMed] [Google Scholar]
- 25.Ghasemi M M, Bakhshaei M, Jamei A S. MJIRI; 2004. Medical Joumal of the Islamic Republic of Iran HEARING LOSS IN HEMODIALYSIS PATIENTS. Vol. 17. [Google Scholar]
- 26.Gafter U, Shvili Y, Levi J, Talmi Y, Zohar Y. Brainstem auditory evoked responses in chronic renal failure and the effect of hemodialysis. Nephron J. 1989;53(01):2–5. doi: 10.1159/000185692. [DOI] [PubMed] [Google Scholar]
- 27.Saeed S, Khan Q U. The Pathological Mechanisms and Treatments of Tinnitus. Discoveries (Craiova) 2021;9(03):e137. doi: 10.15190/d.2021.16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Hung S H, Xirasagar S, Cheng Y F, Kuo N W, Lin H C. Association of Chronic Kidney Disease with Prior Tinnitus: A Case-Control Study. J Clin Med. 2022;11(24):7524. doi: 10.3390/jcm11247524. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Shih C P, Lin H C, Chung C H et al. Increased risk of tinnitus in patients with chronic kidney disease: A nationwide, population-based cohort study. PLoS One. 2017;12(08):e0183192. doi: 10.1371/journal.pone.0183192. [DOI] [PMC free article] [PubMed] [Google Scholar]