EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN.

, 2005
Mahmoud & Abdelsalam
__________________________________________________________________________________

EVALUATION OF AUDITORY FUNCTION IN CHILDREN

WITH CHRONIC RENAL FAILURE
By
Essam Aly Mahmoud and Montaser Abdelsalam Hafez**
Departments of ENT and Audiology Unit,
*Assiut and **El-Menia Faculty of Medicine
*

ABSTRACT:
This study was conducted on 38 children with chronic renal failure all under
regular haemodialysis for more than two years. Twenty five normal healthy children
served as a control. They were subjected to clinical examination in the audilogy unit in
Assiut University Hospital. The examination included otoscopic examination, basic
audiological assessment, auditory brain stem response (ABR) and transient evoked
otoacoustic emission (TEOAE). Twenty patients had bilateral mild high frequency
sensorineural hearing loss (SNHL). Eight had bilateral moderate to severe SNHL and
ten had normal hearing threshold . All are subjected to examination 1-2 days before
dialysis session. TEOAE and ABR test was carried out for those whose ears has
normal hearing threshold . No response in TEOAE (fail) was obtained in 10% of them
but none of the control and a partial pass response in 40% versus 10% of the controls
(P< 0.001). The mean overall echo-level and reproducibility were significantly lower in
patients than in the controls. The overall echo-levels did not correlate with serum urea,
creatinine, serum sodium or potassium and also for ABR results. The ABR results
showed significantly elongated III, V peak latencies as well as I-III and I-V interpeak
latencies compared to the controls. Cochlear dysfunction was mainly at low frequency
band. The changes in the ABR reflect sub clinical disturbances in neural conduction of
auditory pathway.
KEYWORDS:
Chronic renal failure
Emissions

Audiometry
ABR.

INTRODUCTION:
Sensorineural hearing loss occurs
in as many as 40% of long term
hemodialysis patients with chronic renal
failure. Before the advent of
haemodialysis and renal transplanttation, uremia patients apparently had
no higher incidence of hearing or
vestibular loss than the general population. Such problems have been attributed to ototoxic medications, electrolyte imbalance, inadequate dialysis or
disease or unknown cause (Bergstrom
et al., 1980).

Otoacoustic

Gatland et al., (1991) studied the

prevalence of sensorineural hearing loss
in patients with chronic renal failure
and threshold changes follo-wing
haemodialysis. They found incid-ence
of hearing loss is 41% in the low, 15%
in the middle and 53% in the high
frequency ranges respectively. They
found no correlations between weight
changes, haematocric, metabolic bone
disease or ototoxic drug history of the
patients and changes in hearing threshold level.
Bazzi et al., (1995) studied the
effect of short term and long term
haemodialysis on hearing in patient
with chronic renal failure. They found

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Mahmoud & Abdelsalam
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incidence of 61.5% sensorineural

hearing loss. There was no correlation
between hearing loss and plasma
creatinine. Patients with plasma urea
>200 mg/dL had higher percentage of
hearing loss (86%) than with plasma
urea <200 mg/dL (69%). They
concluded that hearing loss in children
with chronic renal failure was mainly
cochlear SNHL.

tigation of the neuro-otological dysfunction associated with renal failure.

Fan et al., (1994) measured brain
stem auditory evoked potentials
(BAEP) in 20 chronic renal failure
patients. They found marked increase in
wave I, III, V peak latencies and I-III,
I-V interpeak latencies and no
correlation between plasma protein,
hemoglobin, urea, creatinine, serum
electrolytes and BAEP measurements.
They realized that BAEP could be used
as objective index in deciding the inner
ear and nervous system damage in
chronic renal failure.

Nikolopoulos et al., (1997)

investigate hearing acuity in young
children suffering from renal insufficiency. They reported that SNHL
(mainly high-frequency) of unknown
cause was found in 30.4% and hearing
loss was not influenced by various
haematological, biochemical and
clinical parameters as blood pressure
and history of ototoxic drug administration. However, hearing loss seemed
to be affected by the method of
management of the renal insufficiency
(more in the haemodialysis group than
in the peritoneal dialysis).

Katedra et al., (2002) investigate

the effects of haemodialysis in children
at the terminal phase of chronic renal
failure (CRF) as a potential factor
responsible for SNHL. They examined
20 child with (CRF) before and after
dialysis using pure tone audiometry,
brain stem evoked potentials (BAEP)
and acoustic otoemissions (TEOAE
and DPOAE). They found significant
SNHL, significantly elongated I, III, V
peak latencies as well as I-III and I-V
interpeak latencies in BAEP of children
with CRF and DPOAE was improved
after dialysis in range of frequencies
which was absent before. They
concluded that ABR and OAEs could
reflects the influence of electro-lyte
disturbances associated with CRF on
auditory function.

Mancini et al., (1996) investgitated the incidence of SNHL in 68

patients who reached chronic renal
failure (CRF) in childhood with aim of
identifying possible risk factors. They
reported 29% SNHL in patients under
conservative treatment, 28% of patients
on hemodialysis, and 47% after renal
transplantation. Also they found a
significant correlation with the administration of ototoxic drugs.

Samir et al., (1998) investigate

the effects of chronic renal failure in
children using transient otoacoustic
emission test (TEOAE). They reported
cochlear dysfunction at low frequency
bands as detected by TEOAE results
and that the overall echo-levels of
TEOAEs did not correlate with serum
urea, creatinine, sodium or potassium.

The clinical utilization of electrophysiological activities of the auditory

system has opened a new era in the
ability to diagnose central auditory
impairment. The most utilized electrophysiological technique for evaluation
of integrity of the central auditory
system is the auditory brain stem
response (ABR). ABR yields valuable
information about the impulse conduction along the brain stem pathway.
Thus, it could be useful in the invest-

Hurks et al., (1995) studied

auditory brain stem (ABR) and
somatosensory evoked potentials

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Mahmoud & Abdelsalam
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(SSEP) in children with chronic renal

failure. They reported a delay in peak I
latency of ABR which is an indication
for peripheral conduction dysfunction.
There was no differences between the
children treated conservatively and
those with continuous peritoneal
dialysis.

between 10 and 18 years old and sex

distribution was (10 female and 28
male).
Control group: n= 25
Consisted of 25 normal healthy
children from those attending the
audiology unit with their family. Their
age and sex distribution matched those
of the study group.

Stanvroulaki et al., (2001)

studied the effect of chronic renal
failure on hearing organ in young
patients using distortion product otoacoustic emissions. They found signifycantly lower amplitudes of DPOAE in
all frequencies >1184 even in patients
with normal pure tone thresholds. They
reported that DPOAE seem to be more
sensitive to incipient cochlear damage
than behavioral threshold in monitoring renal patients.

Criteria for selection of the study

group:
- The study group had the criteria of
chronic renal failure as the following :
Clinical manifestations as :
Pallor (anemia), polyurea, polydipsia,
edema, hypertension, vomiting.
(Bergstein , 2000) .
- Laboratory abnormalities including :
Anemia, leukopenia,
thrombocytopenia, hyperkalemia,
hyponatremia
And elevated serum urea and creatinin
level .
- The normal of blood chemistry in
normal child age (10-18) was :
Serum urea (3.0-5.7) m mol/L
Serum creatinine (0.3-0.7)m mol/L
Serum sodium (138-145) m mol/L
Serum potassium(3.5-6.0) m mol/L
(Nelson,2000) .
- No history of ear disease or other
systemic diseases that cause hearing
loss.
- Normal otoscopic examination.
-Normal blood pressure and heart
examination.
B- Methods:
The children for the study group
were examined once between the
dialysis sessions i.e. 1-2 days before the
dialysis session.
All subjects of the study and
control group were subjected to the
following:
- ENT examination.
- Pure tone audiometry (PTA): at active
intervals from 250 Hz to 8000 Hz for
air conduction and 500 Hz to 4000 Hz
for bone conduction.

This study was designed to

explore the effects of chronic renal
failure on hearing function of young
children and the use of otoacoustic
emission tests and evoked auditory
potentials as auditory brain stem
response (ABR) as an objective tests to
investigate the disturbances in this
function.
AIM OF THE WORK:
1- The aim of this study was to clarify
the effect of chronic renal failure in
children on the cochlea and central
auditory pathway specially on the brain
stem level and to determine the degree
of hearing loss if present.
2- To evaluate the sensitivity of TEOAE
and ABR tests as objective methods for
evaluation of auditory function.
MATERIALS AND METHODS:
Materials:
Study group: n= 38
The group consisted of 38 children suffering from chronic renal failure
and undergoing haemmodialysis in the
pediatric unit for renal failure for more
than two years. Their age ranged

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Mahmoud & Abdelsalam
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Normal hearing threshold (0-25 dB HTL)

Mild hearing loss (26-45 dB HL )
Moderate hearing loss (46-70 dBHL )
Severe hearing loss (71-90 dBHL).
(Katz ,1990 )
- Auditory brain stem response (ABR):
was performed monaurally using
alternating dick at 90 dBnHL intensity
level with repetition rate 21:1
puls/second. The absolute latency and
interpeak latency value of each tracing
was obtained and saved for further
analysis.

According to this classification, the

results of TEOAE were interpreted into
one of the three categories.
Pass: the response was 3 dB or above in
each of the tested frequency bands
(1,2,3, and 4 K Hz ) .
Partial pass: The response was present
in at least one of the tested frequency
bands.
Fail: no cochlear response was present
at any of the tested frequency bands.
For both ABR and TEOAEs the
comparison between both study and
control groups were done only for
children with normal hearing threshold.
- Statistical analysis was performed
using t-student test to compare
between the study and control group.
- The study group children were
diagnosed clinically as chronic renal
failure and all fulfilled the criteria for
renal failure as the laboratory finding
for each child were estimated.

The following ABR parameters were

applied:
Click duration: 100 ms
Number of sweeps: 2000
Delay: zero
Gain: 100 k
Low pass frequency: 100 Hz
High pass frequency: 3k
Sweep time: 12 ms
Electrode placement: active on the
vertex, reference on the mastoid of the
test ear and ground electrode on the
other mastoid.
- Transient evoked otoacoustic emission
(TEOAE): Using a stimulus non-linear
click of 80 micro second duration.
The intensity was adjusted to be
approximately 85 dBspl .
TEOAE were analyzed during the 20 ms
after the stimulus and a total of 26
average on each two buffers (A & B)
were stored fore analysis .
In this study the results were interpreted
according to Maxon et al., ,1993 .
A response was considered present
whenever their was an emission 3dB
signal/ noise ratio or above (i.e. 3 dB
above noise floor) in any frequency
band .

RESULTS
Study group:
This group consisted of 38
children with CRE. The results of the
study group showed significantly high
frequency SNHL ranged from mild to
moderately severe.
There were 20 child has bilateral
mild high frequency SNHL, eight had
bilateral moderate to severe SNHL and
ten children had bilateral normal
hearing threshold.
Table (1) showed a statistically
significant increase in hearing threshold level at frequencies 2, 4, 8 KHz
when compared to control group.

Table (1): Comparison of the mean (X) and SD of the study and control groups for
average pure tone hearing thresholds of both right and left ears.
Frequency

Study group
Mean
SD

Control group
Mean
SD

242

Significance
P

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250
500
1000
2000
4000
8000

15
20
25
35
50
65

4.08
5.41
3.90
6.12
6.19
3.15

15
22
24
23
25
25

Results of transient evoked otoacoustic emission:

TEOAE was done only for 10 children
of the study group, those having
normal hearing threshold. Table (2)
showed that these was no response in
TEOAE (fail) in 10% of the study
group but none of the control group
and 40% partial response versus 10%

4.05
3.21
5.10
0.34
2.56
3.41

0.32
0.21
0.25
< 0.001*
< 0.001*
< 0.001*

of the controls (P< 0.001). The results

of TEOAE overall response and
reproducibility were significantly lower
in the study group when compared to
the control group (Tables 2 and 3). The
lower frequencies of reproducibility
were mainly affected

Table (2): The percentage of each category of TEOAE in the study and control groups
Category
Pass
Partial pass
Fail
Total

Study group
No.
5
4
1
10

Control group

%
50%
40%
10%
100%

No.
9
1
zero
10

%
90%
10%
0%
100%

Table (3): Comparison of TEOAE overall response level, repro ducibility % and
reproducibility at each frequency band in the control and study groups.
TEOAEs

Study group
Mean
SD
Response
7.57
4.16
Whole repro %
66.2
13.4
0.5 KHz
70.4
11.4
1 KHz
60.3
21.2
2 KHz
87.5
16.1
3 KHz
90.5
22.1
4 KHz
75.3
26.2
P< 0.05 significant
Results of auditory brain stem
response testing:
The results of ABR in the study
group were compared only for children
with normal hearing threshold . They
showed significant delay in the latency
of wave III and V, also the interpeak

Control group
Significance
Mean
SD
P
19.5
4.51
0.001**
96.7
5.32
0.006**
90.5
16.11
0.04*
80.5
12.4
0.01*
90.7
17.3
0.34
95.3
22.4
0.21
75.2
18.4
0.35
P< 0.001 highly significant
latencies I-III and I-V were
significantly delayed when compared to
the control group at intensity level 90
dBnHL with RR 21.2. This was shown
in Tables from (4) to (7).

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Table (4): Comparison of the ABR wave latency mean and SD in the control and study
groups at 90 dBnHL and RR 21.1 for the right ear.
Wave
I
III
V

Study group
Mean
SD
1.55
0.31
4.11
0.25
6.21
0.14

Control group
Mean
SD
1.41
0.21
3.51
0.22
5.72
0.31

Significance
P
0.13
0.001**
0.001**

Table (5): Comparison of the ABR wave latency mean and SD in the control and study
groups at 90 dBnHL and RR 21.1 for the left ear.
Wave
I
III
V

Study group
Mean
SD
1.59
0.25
4.25
0.31
6.12
0.51

Control group
Mean
SD
1.32
0.41
3.62
0.14
5.82
0.21

Significance
P
0.23
0.001**
0.001**

Table (6): Comparison of the ABR interpeak latency mean and SD in the control and
study groups at 90 dBnHL and RR 21.1 for the right ear.
Interpeak
Latency
I III
IV

Study group
Mean
SD
2.56
0.25
4.66
0.41

Control group
Mean
SD
2.12
0.31
4.21
0.25

Significance
P
0.01*
0.02*

Table (7): Comparison of the ABR interpeak latency mean and SD in the control and
study groups at 90 dBnHL and RR 21.1 for the left ear.
Interpeak
Study group
Control group
Significance
Latency
Mean
SD
Mean
SD
P
I III
2.66
0.42
2.13
0.11
0.05*
IV
4.35
0.43
4.12
0.22
0.04*
Table (8): Results of correlation coefficient (r) between different audiological
parameters and biochemical values measured in the study group .
Audiological
parameters
PTA threshold
Average
ABR latency
For wave V

Biochemical
Measures
Na
Potassium
Blood urea
Creatinine
Na
Potassium
Blood urea
244

Correlation ( r )

Significance

- 0.1917536
0.9913458
-0.3458893
0.6778321
-0.155978
0.1145887
-0.8765127

Insignificant
Insignificant
Insignificant
Insignificant
Insignificant
Insignificant
Insignificant

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ABR interpeak
I-V .
OAE response
In dBspL

Creatinen
Na
Potassium
Blood urea
Creatinine
Na
Potassium
Blood urea

-0.9845332
0.9112456
0.9983564
-0.8755214
-0.9665231
0.9953126
0.1332876
-0.3466794

Insignificant
Insignificant
Insignificant
Insignificant
Insignificant
Insignificant
Insignificant
Insignificant

No correlations were found between the serum urea, creatinine, sodium or

potassium and PTA, TEOAE or ABR findings.
DISCUSSION:
In this study their were
statistically significant difference
between the study and control group in
pure tone threshold. There were 20
child has bilateral mild high frequency
SNHL, eight had moderate to severe
and ten had normal hearing threshold
level as shown in Table (1). Hearing
loss mainly sensorineural type, involving high frequencies 2, 4 and 8 KHz.
There were no correlation between
hearing threshold level and other
factors as blood urea, creatinine or
sodium and potassium serum levels.

investigate the incidence of SNHL in

young children with chronic end stage
renal failure. They reported incidence
of 29% SNHL in patients with conservative treatment, 28% of patients on
haemodialysis and 47% after renal
transplantation.
The results of TEOAEs test
showed statistically significant decrease in overall response amplitude and
at low frequency bands below 2 KHz
(Table 3). These results agreed with the
studies on otoacoustic emissions by
Katedra et al., (2002) and Samir et al.,
(1998). They investigated the effect of
electrolyte disturbances in children with
chronic renal failure on hearing
function using EOAEs test to investtigate cochlear function. They reported
significant decrease in the amplitude of
TEOAE and DPOE in children due to
chronic renal failure and that long term
dialysis (duration of dialysis) was
correlated to the effects on cochlear
function.

These results agreed with results

of many studies including Bergstrom et
al., (1980), Gatland et al., (1991) and
Bazzi et al., (1995); they reported high
frequency SNHL in patients with
chronic renal failure after dialysis and
correlated to the duration of dialysis
and duration of illness, but single
session dialysis appears to had no effect
on hearing organ. Also Nikolopoulous
et al., (1997) agreed with the results of
this study. They investigated hearing
acuity in young children and reported
mainly high frequency SNHL which is
not corre-lated to various
haemological, bioche-mical and other
clinical parameters.

The results of auditory brain stem

response testing showed signify-cantly
elongated III, V peak latencies as well
as I-III and I-V interpeak latencies
when compared to the control group.
This indicating that chronic renal failure
not only affects cochlear function but
also results in delayed neural
conduction in the brain stem.

Mancini et al., (1996) agreed

with the results of this study. They

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These results agreed with the

results obtained by Fan et al., (1994)
and Kalcolra et al., (2002). They used
evoked potential testing as a tool for
investigating auditory pathway and they
found that chronic renal failure in
_hildren leads to significant elongation
in wave I, III, V peak latencies and IIII, I-V interpeak latency values and
their were no correlations between
these findings and plasma protein levels
or haemoglobin, urea, creatinine and
serum electrolytes. All these results also
agreed with the results of this study in
which no correlation also were found
between TEOAE amplitude decrease or
ABR values and that of serum urea,
creatinine or sodium and potassium
serum levels.
Ozturan et al., (1998) agreed
with the results of this study. They used
audiometry and DPOAE to investigate
the effects of chronic renal failure on
hearing. They reported high frequency
SNHL, but the acute effect of dialysis
has no direct effect on hearing
threshold level.

function and nerve conduction along

the brain stem. This could be elicited by
the changes in ABR findings and
TEOAEs test results in this study.
CONCLUSIONS:
- Chronic renal failure in children under
regular haemodialysis results in mild to
moderately severe SNHL affecting
mainly high frequency region at 3-8
KHz.
- Auditory function in children with
chronic renal failure was affected at the
levels of both cochlea and brain stem
and otoacoustic emission, ABR testing
could be used as objective tests for
evaluation of these changes.
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1. Bazzi C, Venturini CT, Pagani
C, Amjo G and Amico G (1995):
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From this study it was apparent
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from 3-8 KHz and both cochlear and
brain stem function are affected most
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