Nowadays chronic renal failure (CRF) originates from diabetes mellitus and from hypertensive renal disease which lead to a progressive and irreversible destruction of nefron mass. Glomerulonephritis used to be the cause of CRF, what it is opposite at the present time. Because of precocious treatment performed today, it is a secondary hypothesis. Many patients with CRF are under a conservative treatment and so need dialysis treatment. (1)
Life expectancy for patients with CRF submitted to dialysis treatment has increased due to late progresses, raising the occurrence of late complications such as hearing impairment (2). The occurrence of hearing impairment in patients under dialysis treatment ranges from 20 to 75% in the literature (1).
Bergstrom suggests that before dialysis treatment and kidney transplantation, patients with CRF did not present higher incidence of hearing impairment in relation to general population, perhaps because of early death of these patients (12).
The influence of dialysis treatment on hearing loss is not very clear. Metabolic alterations and hydroelectrolytic disturbance seem to be associated, though choclea of patients under dialysis treatment is sensitive to different attacks including base disease-related (4).
The target of our study was to examine the occurrence of hearing impairment, tinnitus and dizziness in patients submitted to dialysis treatment relating alterations found with its duration, the use of ototoxic drugs, levels of blood urea and anemia. RECORDS AND METHODS
35 patients with CRF were selected and submitted to dialysis treatment at CLINEMGE (Clínica de Hemodiálise - Minas Gerais - Hemodialysis clinic). Age, sex, period of dialysis treatment, previous kidney transplantation, anemia, hypercholesterolemia, the use of furosemide and eritropoentine were analyzed and related to presence of dizziness, vertigo, tinnitus and hearing impairment. We considered anemia-carrier patients the ones who had level of hemoglobin lower than 12 mg/dl to men and 14 mg/dl to women. Presence of hypercholesterolemia was taken into consideration when serum levels of cholesterol were above 240mg/dl. Dizziness, vertigo and tinnitus were evaluated through interviews.
Patients with middle ear pathology and conduction hypoacusis were deprived. Otoscopy and tonal audiometry were performed in all patients (Interacoustics AD28 audiometer). It was tested the frequencies of 250. 500. 1000. 2000. 3000. 4000. 5000. 6000. 7000 and 8000 Hz. Hearing losses were classified as mild (21 to 30dB), moderate (31 to 60dB), severe (61 to 90dB) and profound (above 91dB).
Statistical analysis was performed through Epiinfo 6.04b program and 95% (p<0.05) was the rate of significance considered.
The study was approved by Ethics Committee in Research of Socor Hospital on June 6, 2005. All patients were informed on the study and through Free and Clear Consent Term. RESULTS
From the 35 studied patients, 24 were male and 11 female aging from 22 to 75 years, with average age of 50.2 years.
The average period patients were submitted to dialysis treatment was 7.9 yeas, raging from 2 to 19 years. (Graph 1)
Graph 1. Distribution of patients during hemodialysis period.
5 patients were submitted to previous kidney transplantation and developed with renal failure and were remained under dialysis treatment. 28 patients (80%), presented anemia and 3 (8.6%) had hypercholesterolemia. 29 (82.9%) were making use of eritropoetine and 14 (40%) of furosemide.
3 (8.6%) patients had intermittent dizziness, 7 (20%) had tinnitus and no patients with vertigo.
Eighteen patients had normal audiometry and 17 (48.5%) had hypoacusis. 8 (22.9%) from these had mild hypoacusis, 6 (17.1%) moderate hypoacusis and 3 (8.6%) severe one. (Graph 2).
Graph 2. Distribution of patients according to hearing loss degree.
From patients with hypoacusis, 10 had sensorineural loss in acute frequencies, 6 in severe and acute frequencies (U inverted curve) and 1 patient in severe frequencies.
In order to perform statistical analysis, we divided patients into two groups, one with patients under 60 years of age and another with patients above 60 years.
There was no expressive statistical difference among hypoacusis, tinnitus and dizziness when related to age, sex, previous kidney transplantation, anemia, hypercholesterolemia, eritropoetine and furosemide use.
From the patients with hypoacusis, 13 were male and 4 were female (Table 1). Hypoacusis and dizziness occurred in two patients at the same time (Table 2). Similarly, hypoacusis and tinnitus occurred in 5 patients at the same time (Table 3) (p>0.05). Graph 3 displays the occurrence of otovestibular symptoms. DISCUSSION
According to our study, occurrence of hypoacusis in patients submitted to dialysis treatment was 48.6%, differing from the literature which ranges from 20 to 75% (1).
Period of dialysis treatment did not represent a risk factor to either hypoacusis or dizziness or tinnitus. According to Bazzi, who compared hypoacusis incidence and period of dialysis treatment, patients under such treatment for more than 10 years presented higher occurrence if compared to patients with less than 10 years of treatment, though with no expressive significance (1).
Only three patients complained of dizziness and another three of tinnitus, without being hypoacusis-related, and no patients complained of vertigo. Before dialysis treatment and kidney transplantation, uremic patients presented increased occurrence of hearing loss and vestibular symptoms assigned to ototoxic medication use, hydroelectrolytic balance and improper dialysis (12). None of them presented dizziness and tinnitus at the same time.
Anemia was not considered a risk factor to hypoacusis, dizziness and tinnitus in the current study. Most of patients are using eritropoetine. The use of this, to anemia control, is related to expressive improvement of hearing. Anemia is an important factor to hearing disorders in patients with CRF (8).
Most of patients presented mild and moderate sensorineural loss with predominance in acute frequencies. No patients complained of fluctuating hypoacusis.
When analyzing audiometric curve, we observed that six patients (37.5%) had a worsening of hearing level in acute and severe frequencies, characterizing an inverted U-curve. Several studies show hypoacusis with predominance in acute frequencies, and possibly related to use ototoxic drugs, age, blood thickness (2.9.3). Gatland demonstrates an incidence of hypoacusis of 41% in low frequencies; 15% in medium frequencies, and 53% in high frequencies. It was also showed an improvement of hearing in low frequencies after dialysis treatment in 38% of the cases, and it can be related to occurrence of endolymphatic hydrops caused by alteration of hydroelectrolytic balance (3).
In our study we cannot conclude if dialysis treatment is a risk factor to hypoacusis for the absence of a control group. The literature has different results. According to Mirahmadi, dialysis treatment is not a risk factor to hypoacusis. He compared audiometry results from patients before the first section of dialysis and from 1 to 5 years afterwards, with no expressive difference (5). This information was confirmed by Henrich during a one-to-four-year follow-up, suggesting that hearing impairment is common in patients with CRF and it is multifactorial (6). There was no expressive worsening on hearing comparing patients under conservative treatment, during dialysis treatment and after kidney transplantation (7). Gierek performed otoacoustic emission and audiometry of brainstem which was altered in patients with CRF before and after first section of dialysis and also 6 months afterwards, and found no worsening on hearing threshold (14). This was confirmed by Serbetcioglu who did not find any differences on tonal audiometry results both before and after dialysis treatment section (15). Opposite to Orendorz-Fraczkowska, who performed tonal and brainstem audiometries and otoacoustic emissions before and after sections of dialysis in 20 patients. The study showed an improvement on hearing threshold after dialysis treatment, what is assigned to improvement of hematological standards (uraemia, hyperkalaemia) (16).
Ozturan, who performed tonal audiometry and otoacoustic emmision by product of distortion both before and after sections of dialysis treatment, comparing patients with and without CRF, concludes that hypoacusis can be assigned to preexistent renal failure (11). CONCLUSION
Hypoacusis in patients submitted to dialysis treatment presents low impact on their quality of life. We did not identify any risky factor statistically expressive to occurrence of otological symptoms and dialysis treatment proved to be a safe otological viewpoint to patients with terminal CRF. BIBLIOGRAPHY
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1. Especialist-degree student in Otorhinolaryngology.
2. Speech Doctor of Socor Hospital.
3. PhD in Otorhinolaryngology by FMUSP - Preceptor Doctor of Otorhinolaryngology Service from Socor Hospital.
Institution: Hospital Socor
Mail address: Juliana Altavilla van Petten Machado
Rua Professor Djalma Guimarães no. 370 casa - Bairro Mangabeiras - Belo Horizonte MG - Cep 30210190 - Phone: (31) 3281-3380. Fax: (31) 3295-1941. E-mail: firstname.lastname@example.org
Work submitted on January 12, 2006 13:07:08. Codigo de Fluxo: 67, SGP - Sistema de Gestão de Publicações (Publication Management System) - RAIO (Revista Arquivos de Otorrinolaringoloria).