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Audiometric changes in patients undergoing hemodialysis and renal transplantation
Audiometric Changes in Patients Undergoing Hemodialysis and Renal Transplantation C. Abaete´ de los Santos, A-R. Wiederkehr Bau´, D.O. d’Avila, E.O. Hausen de Souza, S. Moussalle, and N.H. Galvan Gomes
A
UDIOMETRIC changes on dialysis patients have been previously reported in adults1 and in children.2,3 However, scarce information is available comparing hearing loss on dialysis and after renal transplantation.4 Apparently, there are no published data comparing hearing acuity in patients undergoing dialysis and after transplantation, to a control group. The aim of this paper was to observe prevalence and patterns of audiometric changes in individuals being submitted to hemodialysis or having undergone kidney transplantation (and hereby with near normal renal function), not affected by Alport’s syndrome, drug toxicity, or acoustic trauma, and to compare them with a healthy control group, matched by sex and age. PATIENTS AND METHODS Forty-five patients on maintenance hemodialysis underwent hearing examination, followed by audiometric evaluation: 90 ears were considered for analysis. Patients with abnormal otoscopic examination, Alport’s syndrome, acoustic trauma, or with suspected toxic drug use were excluded. Audiometry was performed in the interval between dialysis and never immediately prior to or following the procedure. They were dialysed for 4 to 5 hours, thrice weekly, to achieve dry-weight using cellulose acetate or polysulfone membranes. Kt/V tests were monthly performed to ascertain adequacy of dialysis. Twenty-five individuals were male, and mean age for the entire group was 40.9 (⫾11.0) years. Average time on dialysis was 22.6 (⫾18.2) months. Forty-three transplant patients (and 86 ears) were considered for analysis. Patients with abnormalities on otoscopic examination, diabetes, Alport’s syndrome, acoustic trauma, toxic drug use, and serum creatinine above 1.8 mg/dL were excluded. Twenty-one patients were male, and mean age was 39.4 (⫾10.0) years. Average pretransplant time on dialysis was 29.9 (⫾28.5) months. Interval between transplant surgery and audiologic-audiometric evaluation was 43.0 (⫾32.9) months. Control group was 40 healthy hospital workers (mean age: 42.7 ⫾ 13.1 years) with no past medical or family history of kidney disease or deafness, matched by sex and age. Eighteen were male and 80 ears were analyzed. Individuals with abnormal otologic examination, diabetes, acoustic trauma, or with history of previous use of toxic drugs were excluded. Tonal-vocal audiometric tests were performed in 128 individuals: 256 ears were examined, and the sample divided, comparing prevalence of hearing loss in each group. An Interacoustic AC40 audiometric device was used, and individuals were tested inside a sound-proof compartment. Intensity of hearing loss was expressed
in decibels (dB) and band of audiofrequency in Hertz (Hz). Normal intensity was considered in the range of 0 to 25 dB. Hearing loss intensity was considered mild when varying between 26 to 40 dB; moderate between 41 to 70 dB; and severe between 71 to 90; profound, above 91 dB. Measured audiofrequencies varied from 250 to 8000 Hz. For statistical analysis, to measure differences between continuous variables and to compare prevalence among groups, parametric tests and chi-square test were used, employing a computer statistical package (SPSS 6.0). Statistically significant differences were considered whenever P ⬍ .05.
RESULTS
Sixty-two percent (56 of 90) of hemodialysis patients had normal audiometric tests; 17.7% (16 of 90) had mild hearing loss at frequencies over 3000 Hz; 14.4% (13 of 90) had moderate loss at frequencies above 2000 Hz; 4.4% (4 of 90) presented severe hearing loss at frequencies above 8000 Hz; and only one had profound hearing disturbance. Transplanted patients presented normal hearing tests in 65.1% (56 of 86); 25.6% (22 of 86) had mild hearing loss at frequencies over 3000 Hz; and 9.3% (8 of 86) had moderate loss at frequencies above 2000 Hz. There were no severe or profound disturbances in this group. Control group had 81.2% (65 of 80) normal audiometric tests; 16.2% (13 of 80) had mild hearing loss; and 2.5% (2 of 80) presented with moderate deficit. Neither severe nor profound changes occurred. Normal audiometric tests were more frequently found in the control group. Mild changes were more prevalent in the transplant group. However, the sum of moderate, severe, and profound audiometric changes was 19.9% on hemodialysis group, against only 9.3% in transplant and 2.5% in control groups (P ⬍ .05) (Table 1). DISCUSSION
It has long been recognized that patients with chronic renal failure have higher prevalence of hearing defects. This From the Departments of Internal Medicine (Division of Nephrology) and Surgery (Division of Otorhinolaryngology), PUCRS School of Medicine, Porto Alegre, Brazil. Address reprint requests to Carlos A. de los Santos, Hospital Sa˜o Lucas da Pucrs, Av Ipiranga 6690. Porto Alegre, RS, Brazil.
© 1999 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0041-1345/99/$–see front matter PII S0041-1345(99)00646-6
Transplantation Proceedings, 31, 3011–3012 (1999)
3011
ABAETE´ DE LOS SANTOS, WIEDERKEHR BAU´, d’AVILA ET AL
3012 Table 1. Prevalence of Audiometric Findings Among Groups
Normal ears Mild changes Moderate changes Severe changes Profound changes
Hemodialysis n ⫽ 90*
Transplant n ⫽ 86*
Control n ⫽ 80*
62.3% 17.7% 14.4%** 4.4% 1.1%
65.1% 25.6%** 9.3% — —
81.2%** 16.2% 2.5% — —
*Number of ears considered for analysis. **P ⬍ .05.
could be particularly—and mainly—attributed to increased incidence of Alport’s syndrome and drug toxicity often found in those individuals. The exclusion of both situations, as well as diabetes and acoustic trauma, from the sample allowed us to see whether hemodialysis and transplantation per se, when compared to a control group, would show differences in hearing performance as measured by audiometry. Surprisingly, mild audiometric changes, viz, hearing losses between 26 to 40 dB and at frequencies above 3000 Hz— considered as the most prevalent changes on dialysis1,3– 6— occurred at a not different frequency in hemodialysis and in control groups; they were significantly increased in transplant patients. Such findings are difficult to explain, since patients with Alport’s syndrome, acoustic trauma, and drug toxicity (which may cause hearing disturbance) were excluded, and transplanted patients were virtually free from the ototoxicity due to uremic environment,7 as their renal function was brought to normal levels, or close. On the other hand, moderate, severe, or profound
changes were almost exclusively present in individuals on chronic hemodialysis. These findings may indicate that dialysis induces important hearing changes independently of any previous pathology. Nevertheless, recent data suggest that patients may start dialysis already presenting sensorineural hearing defects, with duration of dialytic treatment not interfering or worsening their hearing loss.8,9 These findings may be in agreement with previously published data supporting the view that a successful renal transplant improves, or even reverses, hearing disturbances found in dialysis patients.10
REFERENCES 1. Kligerman AB, Solangi KB, Ventry IM, et al: Laryngoscope 91:583, 1981 2. Bergstrom L, Thompson P: Int J Pediat Otorhinolaryngol 5:227, 1983 3. Nikolopoulos TP, Kandiloros DC, Segas JV, et al: Clin Otolaryngol 22:222, 1997 4. Mancini ML, Strologo LD, Bianchi PM, et al: Pediat Nephrol 10:38, 1996 5. Gatland D, Tucker B, Chalstrey S, et al: J Royal Soc Med 84:587, 1991 6. Ozturan O, Lams S: Orl J 60:306, 1998 7. Tyler HR: N Engl J Med 292:1075, 1975 8. Kusakari J, Hara A, Takeyama M, et al: Auri Nasus Larynx 19:105, 1992 9. Bazzi C, Venturini CT, Pagani C, et al: Nephrol Dial Transplant 10:1805, 1995 10. Mitschke H, Schmidt P, Kopsa H, et al: N Engl J Med 292:1062, 1975
A
UDIOMETRIC changes on dialysis patients have been previously reported in adults1 and in children.2,3 However, scarce information is available comparing hearing loss on dialysis and after renal transplantation.4 Apparently, there are no published data comparing hearing acuity in patients undergoing dialysis and after transplantation, to a control group. The aim of this paper was to observe prevalence and patterns of audiometric changes in individuals being submitted to hemodialysis or having undergone kidney transplantation (and hereby with near normal renal function), not affected by Alport’s syndrome, drug toxicity, or acoustic trauma, and to compare them with a healthy control group, matched by sex and age. PATIENTS AND METHODS Forty-five patients on maintenance hemodialysis underwent hearing examination, followed by audiometric evaluation: 90 ears were considered for analysis. Patients with abnormal otoscopic examination, Alport’s syndrome, acoustic trauma, or with suspected toxic drug use were excluded. Audiometry was performed in the interval between dialysis and never immediately prior to or following the procedure. They were dialysed for 4 to 5 hours, thrice weekly, to achieve dry-weight using cellulose acetate or polysulfone membranes. Kt/V tests were monthly performed to ascertain adequacy of dialysis. Twenty-five individuals were male, and mean age for the entire group was 40.9 (⫾11.0) years. Average time on dialysis was 22.6 (⫾18.2) months. Forty-three transplant patients (and 86 ears) were considered for analysis. Patients with abnormalities on otoscopic examination, diabetes, Alport’s syndrome, acoustic trauma, toxic drug use, and serum creatinine above 1.8 mg/dL were excluded. Twenty-one patients were male, and mean age was 39.4 (⫾10.0) years. Average pretransplant time on dialysis was 29.9 (⫾28.5) months. Interval between transplant surgery and audiologic-audiometric evaluation was 43.0 (⫾32.9) months. Control group was 40 healthy hospital workers (mean age: 42.7 ⫾ 13.1 years) with no past medical or family history of kidney disease or deafness, matched by sex and age. Eighteen were male and 80 ears were analyzed. Individuals with abnormal otologic examination, diabetes, acoustic trauma, or with history of previous use of toxic drugs were excluded. Tonal-vocal audiometric tests were performed in 128 individuals: 256 ears were examined, and the sample divided, comparing prevalence of hearing loss in each group. An Interacoustic AC40 audiometric device was used, and individuals were tested inside a sound-proof compartment. Intensity of hearing loss was expressed
in decibels (dB) and band of audiofrequency in Hertz (Hz). Normal intensity was considered in the range of 0 to 25 dB. Hearing loss intensity was considered mild when varying between 26 to 40 dB; moderate between 41 to 70 dB; and severe between 71 to 90; profound, above 91 dB. Measured audiofrequencies varied from 250 to 8000 Hz. For statistical analysis, to measure differences between continuous variables and to compare prevalence among groups, parametric tests and chi-square test were used, employing a computer statistical package (SPSS 6.0). Statistically significant differences were considered whenever P ⬍ .05.
RESULTS
Sixty-two percent (56 of 90) of hemodialysis patients had normal audiometric tests; 17.7% (16 of 90) had mild hearing loss at frequencies over 3000 Hz; 14.4% (13 of 90) had moderate loss at frequencies above 2000 Hz; 4.4% (4 of 90) presented severe hearing loss at frequencies above 8000 Hz; and only one had profound hearing disturbance. Transplanted patients presented normal hearing tests in 65.1% (56 of 86); 25.6% (22 of 86) had mild hearing loss at frequencies over 3000 Hz; and 9.3% (8 of 86) had moderate loss at frequencies above 2000 Hz. There were no severe or profound disturbances in this group. Control group had 81.2% (65 of 80) normal audiometric tests; 16.2% (13 of 80) had mild hearing loss; and 2.5% (2 of 80) presented with moderate deficit. Neither severe nor profound changes occurred. Normal audiometric tests were more frequently found in the control group. Mild changes were more prevalent in the transplant group. However, the sum of moderate, severe, and profound audiometric changes was 19.9% on hemodialysis group, against only 9.3% in transplant and 2.5% in control groups (P ⬍ .05) (Table 1). DISCUSSION
It has long been recognized that patients with chronic renal failure have higher prevalence of hearing defects. This From the Departments of Internal Medicine (Division of Nephrology) and Surgery (Division of Otorhinolaryngology), PUCRS School of Medicine, Porto Alegre, Brazil. Address reprint requests to Carlos A. de los Santos, Hospital Sa˜o Lucas da Pucrs, Av Ipiranga 6690. Porto Alegre, RS, Brazil.
© 1999 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0041-1345/99/$–see front matter PII S0041-1345(99)00646-6
Transplantation Proceedings, 31, 3011–3012 (1999)
3011
ABAETE´ DE LOS SANTOS, WIEDERKEHR BAU´, d’AVILA ET AL
3012 Table 1. Prevalence of Audiometric Findings Among Groups
Normal ears Mild changes Moderate changes Severe changes Profound changes
Hemodialysis n ⫽ 90*
Transplant n ⫽ 86*
Control n ⫽ 80*
62.3% 17.7% 14.4%** 4.4% 1.1%
65.1% 25.6%** 9.3% — —
81.2%** 16.2% 2.5% — —
*Number of ears considered for analysis. **P ⬍ .05.
could be particularly—and mainly—attributed to increased incidence of Alport’s syndrome and drug toxicity often found in those individuals. The exclusion of both situations, as well as diabetes and acoustic trauma, from the sample allowed us to see whether hemodialysis and transplantation per se, when compared to a control group, would show differences in hearing performance as measured by audiometry. Surprisingly, mild audiometric changes, viz, hearing losses between 26 to 40 dB and at frequencies above 3000 Hz— considered as the most prevalent changes on dialysis1,3– 6— occurred at a not different frequency in hemodialysis and in control groups; they were significantly increased in transplant patients. Such findings are difficult to explain, since patients with Alport’s syndrome, acoustic trauma, and drug toxicity (which may cause hearing disturbance) were excluded, and transplanted patients were virtually free from the ototoxicity due to uremic environment,7 as their renal function was brought to normal levels, or close. On the other hand, moderate, severe, or profound
changes were almost exclusively present in individuals on chronic hemodialysis. These findings may indicate that dialysis induces important hearing changes independently of any previous pathology. Nevertheless, recent data suggest that patients may start dialysis already presenting sensorineural hearing defects, with duration of dialytic treatment not interfering or worsening their hearing loss.8,9 These findings may be in agreement with previously published data supporting the view that a successful renal transplant improves, or even reverses, hearing disturbances found in dialysis patients.10
REFERENCES 1. Kligerman AB, Solangi KB, Ventry IM, et al: Laryngoscope 91:583, 1981 2. Bergstrom L, Thompson P: Int J Pediat Otorhinolaryngol 5:227, 1983 3. Nikolopoulos TP, Kandiloros DC, Segas JV, et al: Clin Otolaryngol 22:222, 1997 4. Mancini ML, Strologo LD, Bianchi PM, et al: Pediat Nephrol 10:38, 1996 5. Gatland D, Tucker B, Chalstrey S, et al: J Royal Soc Med 84:587, 1991 6. Ozturan O, Lams S: Orl J 60:306, 1998 7. Tyler HR: N Engl J Med 292:1075, 1975 8. Kusakari J, Hara A, Takeyama M, et al: Auri Nasus Larynx 19:105, 1992 9. Bazzi C, Venturini CT, Pagani C, et al: Nephrol Dial Transplant 10:1805, 1995 10. Mitschke H, Schmidt P, Kopsa H, et al: N Engl J Med 292:1062, 1975