Abstract
(1) To study the prevalence of sensorineural hearing loss among chronic renal failure patients. (2) To study the correlation between degree of hearing loss and the duration of chronic renal failure. This cross sectional study was conducted in the department of Otorhinolaryngology and Head and Neck Surgery at KAHER’s Jawaharlal Nehru Medical College and KLEs Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi from January 2018 to December 2018. 60 ears (30 patients) with chronic renal failure were included in the study. All 60 ears were subjected to ENT examination, pure tone audiometry and measurement of glomerular filtration rate. Patients with type 2 diabetes mellitus, suppurative otitis media, and other known causes of sensorineural hearing loss were excluded. The prevalence of sensorineural hearing loss was calculated among the chronic renal failure patients. The correlation, if any, was studied by statistical analysis between SNHL and duration of chronic renal failure, as well as type and degree of hearing loss. Sensorineural hearing loss was seen in 51.67% of the 60 ears with 18.33% had mixed hearing loss (p < 0.0001). Robust correlation was seen between severity of SNHL and the duration of chronic renal failure. Positive correlation was seen between SNHL and age of the patient. High prevalence of SNHL was seen in the chronic renal failure patients. Long standing cases had tendency of worse hearing levels. Age of the patients also seemed to have a positive correlation with SNHL severity. While evaluating a chronic renal failure patient, auditory impairment should always be kept in mind.
Keywords: Sensorineural hearing loss, Chronic renal failure, Pure tone audiometry, GFR
Introduction
Chronic renal failure (CRF) affects the function of almost every organ system in the body [1]. Accumulation of uremic toxins and prolonged hemodialysis will affect almost every tissue, including the auditory system [2]. The effects of CRF on hearing can be divided in two categories: Effects of the disease and effects of hemodialysis [3].
The exact pathophysiological mechanism underlying the presence of hearing loss among CRF patients is unknown. The kidney and the stria vascularis of the cochlea share physiological, ultrastructural, and antigenic similarities that could explain the association between CRF and hearing loss [4].
The inner ear is dependent on homeostasis of water and electrolytes. Defect in cation gradient of endolymphatic fluid, can alter the hearing properties [5]. Defects in microcirculation within the inner ear principally causes an electrolytic imbalance with the resultant impairment of endocochlear potential and sensory transduction [6]. The etiopathological mechanisms reported will alter the osmotic changes resulting in loss of hair cells, collapse of the endolymphatic space, oedema and atrophy of specialized auditory cells [4].
The degree of hearing loss may give an indication of the extent of damage to auditory function whereas the type of hearing loss may distinguish between lesion in outer and middle ear (conductive hearing loss) or cochlea and the neural pathways (SNHL) [2].
Considering the importance of hearing loss in CRF and the present diversity about its presence, type, mechanisms, treatment and prognosis, this study was conducted to understand the relationship between chronic renal failure and sensorineural hearing loss.
Materials and Methods
This cross sectional study was conducted in the Department of Otorhinolaryngology and Head and Neck Surgery at KAHER’s Jawaharlal Nehru Medical College and KLE’s Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi from January 2018 to December 2018.
30 patients (60 ears) with chronic renal failure were included in the study. All 60 ears were subjected to ENT examination, pure tone audiometry and measurement of glomerular filteration rate ({(140 − age) × weight/(72 × Scr)} × 0.85 (if female) ml/min/1.73 m2). Patients with type 2 diabetes mellitus, suppurative otitis media, Meniere’s disease were excluded. The prevalence of sensorineural hearing loss was calculated among the chronic renal failure patients.
The correlation, if any, was studied between SNHL and duration of chronic renal failure, as well as type and degree of hearing loss, and the data was analysed statistically by Chi square test, two way ANOVA test, Tukeys multiple posthoc procedure.
Results
Sensorineural hearing loss was seen in 51.67% of the 30 cases (60 ears) and 18.33% with mixed hearing loss (p < 0.0001). 20 male cases and 10 female cases were considered. More number of patients were seen in the age group of 18–29 years with significant p value of 0.0311 and 40–49 years, with positive p value of 0.0355 and mean age was 37.83 (Fig. 1). On considering the duration, 24 ears were below 2 years of CRF whereas 36 ears were above 2 years. Chi square test was used to know the correlation between the gender and duration of the disease, in our study it is seen that males with CRF more than 2 years and females with CRF less than 2 years had significant effect on hearing with p value of 0.0010, but the overall incidence was high in patients with more than 2 years of the disease with positive p value of 0.0001 (Fig. 2).
Fig. 1.
Distribution of patients in two groups of duration of CRF by age groups
Fig. 2.
Distribution of male and female patients in two groups of duration of CRF
PTA values and duration of the disease were analysed using two way ANOVA test, it revealed positive correlation with p value of 0.0003, indicating that duration plays pivotal role in causing hearing loss (Fig. 3).
Fig. 3.
Comparison of age groups and duration of CRF (< 2 years and > 2 years) with PTA scores
Positive correlation was seen between SNHL and age of the patient and duration of the disease using Chi square test, all the age groups showed statistically significant p value (0.0010) indicating prevelence of sensorineural hearing loss. Robust correlation was seen between severity of SNHL and the duration of chronic renal failure. Of the 60 ears, 31 ears had SNHL, 11 ears had mixed hearing loss and 18 had normal hearing, SNHL being the highest (Table 1). Out of 31 ears with SNHL, 5 ears were less than 2 years and 26 ears belonged to patients with more than 2 years of CRF. It is noted that SNHL is more prevalent in disease with duration of more than 2 years and majority of them had the hearing loss between mild (12) and moderate (9) degree of hearing loss, so to summarise SNHL is the most common type of hearing loss with mild to moderate degree in patients suffering with CRF with more than 2 years of duration as compared to less than 2 years (Table 2).
Table 1.
Comparison of two groups of duration of CRF with type of hearing loss in males, females and as a total
| Gender | Type of hearing loss | < 2 years | % | > 2 years | % | Total | % |
|---|---|---|---|---|---|---|---|
| Males | Normal | 8 | 80.00 | 0 | 0.00 | 8 | 20.00 |
| Sensory neural hearing loss | 2 | 20.00 | 21 | 70.00 | 23 | 57.50 | |
| Mixed hearing loss | 0 | 0.00 | 9 | 30.00 | 9 | 22.50 | |
| Total | 10 | 100.00 | 30 | 100.00 | 40 | 100.00 | |
| Chi square = 30.2611, p = 0.0001* | |||||||
| Female | Normal | 10 | 71.43 | 0 | 0.00 | 10 | 50.00 |
| Sensory neural hearing loss | 3 | 21.43 | 5 | 83.33 | 8 | 40.00 | |
| Mixed hearing loss | 1 | 7.14 | 1 | 16.67 | 2 | 10.00 | |
| Total | 14 | 100.00 | 6 | 100.00 | 20 | 100.00 | |
| Chi square = 8.6903, p = 0.0130* | |||||||
| Total | Normal | 18 | 75.00 | 0 | 0.00 | 18 | 30.00 |
| Sensory neural hearing loss | 5 | 20.83 | 26 | 72.22 | 31 | 51.67 | |
| Mixed hearing loss | 1 | 4.17 | 10 | 27.78 | 11 | 18.33 | |
| Total | 24 | 100.00 | 36 | 100.00 | 60 | 100.00 | |
| Chi square = 8.7395, p = 0.0001* | |||||||
*p < 0.05
Table 2.
Pair wise comparison of age groups and duration of CRF (< 2 years and > 2 years) with PTA scores by Tukeys multiple posthoc procedure
| Interactions | 18–29 years with < 2 years of duration | 18–29 years with > 2 years of duration | 30–39 years with < 2 years of duration | 30–39 years with > 2 years of duration | 40–49 years with < 2 years of duration | 40–49 years with > 2 years of duration | 50–59 years with < 2 years of duration | 50–59 years with > 2 years of duration |
|---|---|---|---|---|---|---|---|---|
| Mean | 25.00 | 52.43 | 19.45 | 60.35 | 13.55 | 35.29 | 11.20 | 59.34 |
| SD | 19.46 | 10.65 | 13.37 | 22.44 | 2.05 | 17.89 | 0.57 | 13.84 |
| 18–29 years with < 2 years of duration | – | |||||||
| 18–29 years with > 2 years of duration | p = 0.0311* | – | ||||||
| 30–39 years with < 2 years of duration | p = 0.9953 | p = 0.0108* | – | |||||
| 30–39 years with > 2 years of duration | p = 0.0106* | p = 0.9950 | p = 0.0039* | – | ||||
| 40–49 years with < 2 years of duration | p = 0.9835 | p = 0.0936 | p = 0.9998 | p = 0.0355* | – | |||
| 40–49 years with > 2 years of duration | p = 0.7241 | p = 0.3799 | p = 0.3530 | p = 0.1367 | p = 0.6458 | – | ||
| 50–59 years with < 2 years of duration | p = 0.9540 | p = 0.0615 | p = 0.9982 | p = 0.0228 | p = 0.9999 | p = 0.5207 | – | |
| 50–59 years with > 2 years of duration | p = 0.0004* | p = 0.9916 | p = 0.0002* | p = 0.9999 | p = 0.0153* | p = 0.0139* | p = 0.0090* | – |
*p < 0.05
Discussion
Chronic renal failure is defined as either kidney damage or glomerular filtration rate less than 60 ml/min for 3 months or more [2]. This is invariably a progressive process that results in end stage renal disease.
Hearing impairment, particularly SNHL, in patients with CRF is a common finding in many studies investigating the influence of renal failure on hearing [7]. The prevalence of hearing loss in India, reported to be 63.5% [8].
Electrolyte disturbances, particularly sodium, water imbalance, hypertension, Vitamin D deficiency, and elevated serum urea levels, are proposed mechanisms for hearing impairment in patients with CRF [9]. Defects in the cationic gradient of endolymphatic fluid can alter hearing properties [5]. Furthermore, alterations in the peripheral and central nervous system, uremic neuropathy, may be involved in hearing impairment associated with CRF [10].
Early identification and active management of patients with renal impairment can improve outcomes. The toxins that accumulate in kidney failure can damage nerves, including those in the inner ear. Mortality in patients with end stage renal disease remains 10–20 times higher, compared to general population. Glomerular filtration rate is the “gold standard” to determine the kidney function. These conditions are subclinical initially but may progress aggressively and eventually can become symptomatic and irreversible.
It needs to be emphasised that the patients presenting with renal failure should be evaluated for hearing loss also along with their general condition evaluation, it helps in early identification and further can be cautioned to avoid ototoxic drugs in the treatment of the disease and helps in preventing rapid deterioration of inner ear.
On comparing our study with other similar studies, it is seen that there is positive relation between SNHL and CRF and there is effect on degree of hearing loss and few discrepancies could be due to factors such as race, genetic variables, environment, audiometry method, haemodialysis and human error.
Conclusion
Chronic renal failure, along with its many complications, is a major health problem today. Among the myriad complications of CRF, sensorineural hearing loss is one of them. Association between CRF and hearing impairment has been observed since many years and multiple studies have confirmed this association.
The above results indicate that there is a real threat of auditory impairment in long standing cases of CRF. As the duration of illness progresses, the degree of hearing loss is seen to worsen indicating that prolonged and continued exposure to the harmful pathological effects i.e. altered ionic imbalance of CRF has a strong bearing on hearing impairment due to physiological, ultrastructural, and antigenic similarities between the kidney and the stria vascularis of the cochlea that could explain the association between CRF and hearing loss [4].
In our study, strong correlation was found between the degree of hearing loss and the duration of CRF and is found to be mild to moderate degree. Correlation was seen between severity of hearing loss with age and duration of the disease but no correlation seen with gender of the patient.
Thus, in conclusion it is important to keep in mind, the auditory complications of CRF while evaluating a renal failure patient especially if the disease is long standing. Routine audiological evaluation in such cases may help in early diagnosis of sensorineural hearing loss and achieving ionic homeostasis may reduce the severity or delay its occurrence.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
The research involving a human participant.
Informed Consent
Written informed consent was obtained from participant included in the study.
Footnotes
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