Introduction: The effect of chronic kidney disease (CKD) on hearing is well documented in the literature. Several studies have investigated the effect of hemodialysis on the peripheral auditory system among individuals with CKD. However, studies investigating the effect of hemodialysis on speech perception and auditory processing abilities are limited. The present study investigated the effect of hemodialysis on few auditory processing abilities and speech perception in noise among adults with CKD. Methods: A total of 25 adults with CKD undergoing hemodialysis regularly participated in the study. Spectral ripple discrimination threshold (SRDT), gap detection threshold (GDT), amplitude-modulation detection threshold (AMDT), and speech recognition threshold in noise (SRTn) were measured before and after hemodialysis. Paired samples “t” test was carried out to investigate the effect of hemodialysis on thresholds. Results: Results showed a significant improvement for SRDT, GDT, AMDT, and SRTn after hemodialysis among individuals with CKD. Discussion: Hemodialysis showed a positive effect on speech perception in noise and auditory processing abilities among individuals with CKD.

Chronic kidney disease (CKD) is a condition in which “the kidneys are damaged and cannot filter waste products (such as creatinine and urea) and fluids from the blood” [Himmelfarb and Ikizler, 2010]. It is a “progressive condition that can lead to total kidney failure, a condition also called end-stage renal disease” [Ramspek et al., 2017]. Kidney dysfunction results in accumulation of waste products, electrolytes, and excess fluids in the body which causes various health problems including hearing loss among individuals with CKD [Kumar et al., 2004]. The treatment for individuals with end-stage renal failure includes hemodialysis or a kidney transplant. Hemodialysis is a process where the patient’s blood is passed through a hemodialysis machine and filtered externally (to remove waste products and extra fluids from the body) and then returned to patient [Berman and Synder, 2012].

Several studies have investigated the short-term effects of hemodialysis on hearing thresholds [Ozen et al., 1975; Johnson and Mathog, 1976; Visencio and Gerber, 1979; Moffat et al., 1990; Gatland et al., 1991; Ozturan and Lam, 1998; Şerbetçioǧlu et al., 2001; Orendorz-Fraczkowska et al., 2002]. However, findings of the above investigations have shown mixed results. In general, majority of the investigations have reported no short-term effects of hemodialysis on hearing thresholds [Johnson and Mathog, 1976; Visencio and Gerber, 1979; Ozturan and Lam, 1998; Şerbetçioǧlu et al., 2001; Orendorz-Fraczkowska et al., 2002]. In contrast, few studies have found an improvement in hearing thresholds after hemodialysis [Ozen et al., 1975; Gatland et al., 1991], and others have reported poorer thresholds after hemodialysis [Moffat et al., 1990]. Similarly, studies investigating the effect of hemodialysis on auditory brainstem response (ABR) and otoacoustic emissions (OAEs) have also found mixed results. Many studies investigating the effect of hemodialysis on the ABR have reported a significantly shorter latency for peaks of the ABR after hemodialysis compared to before hemodialysis [Rossini et al., 1984; Pratt et al., 1986; Magliulo et al., 1987; Niedzielska et al., 1999; Orendorz-Fraczkowska et al., 2002; Aspris et al., 2008], while other studies have found no effect of hemodialysis on the latency of peaks of the ABR [Gierek et al., 2002]. In contrast, very few studies investigating the effect of hemodialysis on the OAE have reported an increase in the amplitude of OAEs after hemodialysis [Orendorz-Fraczkowska et al., 2002], while other studies have reported no difference in the amplitude of OAEs before and after hemodialysis [Ozturan and Lam, 1998; Gierek et al., 2002].

The effect of hemodialysis on peripheral auditory system among individuals with CKD is well documented in the literature. Further, limited studies have investigated speech perception and auditory processing abilities of individuals with CKD. D’Andrea et al. [2013] reported poorer performance among half of the individuals with CKD on staggered spondaic word test [D’Andrea et al., 2013]. Few studies have reported poorer auditory processing and speech perception in noise among individuals with CKD [Kumar et al., 2021; Jain et al., 2022]. However, none of the studies have investigated the effect of hemodialysis on speech perception and auditory processing abilities. Thus, the present study was carried out to investigate the short-term effect of hemodialysis on spectral processing, temporal processing, and speech perception in noise abilities among individuals with CKD.

Participants

Adults with CKD undergoing hemodialysis regularly and having hearing thresholds less than 25 dB HL at octave frequencies from 250 Hz to 4,000 Hz in both ears served as participants for the study. A total of 78 adults aged between 40 and 60 years were identified for the study. All the participants underwent hearing screening, 25 participants were found to have hearing threshold less than 25 dB HL at octave frequencies from 250 Hz to 4,000 Hz in both ears. Thus, a total of 25 adults with CKD undergoing hemodialysis regularly (thrice per week) for 2–3 years participated in the study. Informed consent was obtained from all participants before they participated in the study. The study was carried out after obtaining approval from the Institutional Ethics Committee.

Procedure

Spectral processing, temporal processing, and speech perception in noise abilities of adults with CKD were measured immediately before and after undergoing hemodialysis. The temporal processing ability was assessed by measuring gap detection threshold (GDT) and amplitude-modulation detection threshold. The spectral processing and speech perception in noise abilities were evaluated by measuring spectral ripple discrimination threshold (SRDT) and speech recognition threshold in noise. The procedure used to measure GDT, amplitude-modulation detection threshold, SRDT, and speech recognition threshold in noise was same as described in earlier investigations [Nambi et al., 2016; Kumar et al., 2020, 2021].

Spectral Ripple Discrimination Threshold

The SRDT was measured using rippled noise. The rippled noise was generated as described by [Won et al., 2007]. Procedure used to generate stimuli and measure the SRDT in the present study was similar to our earlier investigations [Nambi et al., 2016; Kumar et al., 2020, 2021]. Spectral ripple noise was used as the stimuli for measuring SRDT. It was generated by adding 200 pure tones from 100 to 5,000 Hz. The amplitudes of the pure tones were determined by a full-wave rectified sinusoidal envelope on a logarithmic scale. The duration of spectral ripple noise was 500 ms. The procedure used to measure the SRDT was similar to an earlier investigation [Kumar et al., 2021]. A two-alternative forced-choice task with a two-down, one-up adaptive procedure was used to estimate the SRDT. On each trial, one target and standard stimuli were presented in a random order. The interstimulus interval was 250 ms. Participants were instructed to identify the interval containing reverse ripple (target stimuli). The test started with ripple density of two ripples per octave, and the ripple density was adaptively varied. After two consecutive positive responses, ripple density was increased by a ratio of 1.414. The ripple density was decreased by a ratio of 1.414 after a negative response. A total of eight reversals were acquired and midpoints of the last six reversals were averaged to obtain the SRDT.

Gap Detection Threshold

The procedure used in the present study for measuring the GDT is described in an earlier investigation [Kumar et al., 2021]. The GDT was measured for gaps in white noise. The white noise was passed through a low-pass filter noise with a cut-off frequency of 5,000 Hz. The GDT was obtained using a two-alternative forced-choice task using the maximum likelihood procedure. On each trial, one standard and target stimuli were presented in a random sequence. A burst of continuous noise was used as standard stimuli, and noise with pause (or gap) in middle of the noise served as target stimuli. The length of the gap was varied adaptively between 1 ms and 20 ms. The duration of both standard and target stimuli was fixed at 500 ms. Participants were instructed to identify the interval containing noise with a gap. The stimuli were presented at a comfortable level (approximately 80 dB SPL). Eight reversals were acquired, and midpoints of the last six reversals were averaged to obtain the GDT.

Amplitude-Modulation Detection Threshold

The amplitude-modulation detection threshold was measured by using amplitude-modulated pure tones. The procedure used in the present study for measuring the amplitude-modulation detection threshold was similar to our earlier investigation [Kumar et al., 2021]. The amplitude of 500 Hz and 4,000 Hz pure tone was sinusoidally modulated at a rate of 8 Hz, 16 Hz, 32 Hz, or 64 Hz. All signals were generated digitally in MATLAB at a sampling rate of 44.1 kHz. The duration of amplitude-modulated tones was 500 ms. A three-alternative forced-choice task with a two-down, one-up procedure was used to estimate the modulation detection threshold. On each trial, one target and two standard stimuli were presented in a random order. The stimuli were presented at a comfortable level (approximately 80 dB SPL). Participants were asked to identify the interval containing the target stimulus, i.e., amplitude-modulated tone. Initially, the modulation depth was set to −10 dB and was adaptively varied in 1 dB steps. A total of eight reversals were acquired, and the average of midpoints of the last six reversals was considered as the modulation detection threshold.

Speech Perception in Noise

The procedure used for measuring speech perception in noise in the present study was similar to our earlier investigations [Nambi et al., 2016; Kumar et al., 2020, 2021]. Speech perception in noise ability was assessed by measuring speech reception threshold in noise. Quick SIN-Kannada test was used to measure the signal-to-noise ratio (SNR) required to understand 50% of speech recognition performance (SNR-50) [Avinash et al., 2010]. Two lists were randomly selected for each participant, and the test was administered. The SNR-50 was computed based on the performance of participants on the second list of sentences. The first list of sentences was used to familiarize participants with the task as a practice trial. During the task, participants were instructed to ignore the noise and repeat sentences. The number of keywords correctly identified by each participant in each sentence was noted, and the total number of keywords correctly identified by each participant was calculated. Based on the number of keywords correctly identified, the SNR-50 was computed using the Spearman-Karber method [Nambi et al., 2016].

Statistical Analysis

Mean and standard deviation for amplitude-modulation detection threshold, GDT, SRDT, and SNR-50 were computed for before and after hemodialysis conditions. The data were subjected to the Shapiro-Wilk test to check whether the data are normally distributed. Results showed that the data of GDT and SNR-50 before and after hemodialysis, SRDT after hemodialysis, and amplitude-modulation detection threshold for modulation rates 8 Hz, 16 Hz, and 32 Hz of 500 Hz carrier tone and modulation rates 8 Hz, 16 Hz, 32 Hz, and 64 Hz of 4,000 Hz carrier tone after hemodialysis were normally distributed. All statistical analyses were carried out using SPSS 19.0.

Temporal and Spectral Processing

Table 1 shows the mean amplitude-modulation detection thresholds across modulation rates for individuals with CKD before and after hemodialysis. The modulation detection thresholds obtained after hemodialysis were better compared to thresholds obtained before hemodialysis, across modulation rates, and carrier frequencies. Further, the amplitude-modulation detection threshold was dependent on the modulation rate of amplitude-modulated tone. The lowest threshold was obtained for the modulation rate of 8 Hz, and the threshold worsened with an increase in the modulation rate of amplitude-modulated tone. In addition, the amplitude-modulation detection threshold for 500 Hz amplitude-modulated tone was better than 4,000 Hz amplitude-modulated tone across the modulation rates. Table 2 shows the mean GDT and SRDT of participants before and after hemodialysis. The GDT and SRDT obtained after hemodialysis were better compared to thresholds obtained before hemodialysis. To investigate if the mean GDT and SRDT are significantly different before and after hemodialysis, paired samples “t” test was carried out. Results showed a significant effect of hemodialysis on GDT (t = 2.961, p = 0.007) and SRDT (t = −4.499, p < 0.001) among individuals with CKD.

Table 1.

Mean and standard deviation (in parentheses) for amplitude-modulation detection threshold across modulation rates for 500 Hz and 4,000 Hz carrier tone before and after hemodialysis

Condition500 Hz4,000 Hz
8 Hz16 Hz32 Hz64 Hz8 Hz16 Hz32 Hz64 Hz
Before hemodialysis −13.7 (4.8) −13.0 (5.8) −11.7 (4.8) −10.4 (4.9) −10.3 (3.8) −9.7 (3.5) −9.1 (2.7) −7.7 (2.1) 
After hemodialysis −16.1 (5.1) −15.0 (4.9) −13.6 (4.4) −11.8 (5.1) −10.6 (4.3) −10.6 (3.6) −9.1 (3.4) −7.9 (2.1) 
Condition500 Hz4,000 Hz
8 Hz16 Hz32 Hz64 Hz8 Hz16 Hz32 Hz64 Hz
Before hemodialysis −13.7 (4.8) −13.0 (5.8) −11.7 (4.8) −10.4 (4.9) −10.3 (3.8) −9.7 (3.5) −9.1 (2.7) −7.7 (2.1) 
After hemodialysis −16.1 (5.1) −15.0 (4.9) −13.6 (4.4) −11.8 (5.1) −10.6 (4.3) −10.6 (3.6) −9.1 (3.4) −7.9 (2.1) 

Amplitude-modulation detection threshold (in dB).

Values in bold indicate that thresholds are significantly different between condition.

Table 2.

Mean and standard deviation (in parentheses) for gap detection threshold, SRDT, and SNR-50 before and after hemodialysis

ConditionGDTSRDTSNR-50
Before hemodialysis 8.1 (2.1) 2.4 (0.9) 0.5 (1.2) 
After hemodialysis 7.1 (2.3) 3.2 (1.1) −0.2 (0.9) 
ConditionGDTSRDTSNR-50
Before hemodialysis 8.1 (2.1) 2.4 (0.9) 0.5 (1.2) 
After hemodialysis 7.1 (2.3) 3.2 (1.1) −0.2 (0.9) 

GDT, gap detection threshold (in ms); SRDT, spectral ripple discrimination threshold (in ripples/octave); SNR-50, speech recognition threshold in noise (in dB).

Values in bold indicate that thresholds are significantly different between before and after hemodialysis.

To investigate whether the modulation detection thresholds are significantly different before and after hemodialysis, paired samples “t” test was performed. Results showed a significant difference for modulation detection thresholds before and after hemodialysis for modulation rates 8 Hz (t(24) = 7.078, p < 0.001), 16 Hz (t(24) = 3.203, p = 0.004), and 32 Hz (t(24) = 3.109, p = 0.005) of 500 Hz amplitude-modulated tone and for modulation rates 16 Hz (t(24) = 2.298, p = 0.031) of 4,000 Hz amplitude-modulated tone. Further, the modulation detection thresholds of modulation rates 8 Hz (t(24) = 0.333, p = 0.742), 32 Hz (t(24) = 0.982, p = 0.982), and 64 Hz (t(24) = 0.432, p = 0.67) of 4,000 Hz amplitude-modulated tone were not significantly different between before and after hemodialysis conditions. Wilcoxon signed-ranks test showed a significant difference for median modulation detection thresholds of 500 Hz amplitude-modulated tone at 8 Hz modulation rate before and after hemodialysis conditions (W = 269, p = 0.004).

Further, to investigate whether the modulation detection thresholds across modulation rates are significantly different between 500 Hz and 4,000 Hz amplitude-modulated tones, Wilcoxon signed-ranks test was carried out separately for before hemodialysis and after hemodialysis conditions. Results showed a significant difference for thresholds between 500 Hz and 4,000 Hz amplitude-modulated tones across modulation rates for both before and after hemodialysis conditions (8 Hz: before hemodialysis (W = 9, p < 0.001), after hemodialysis (W = 4, p < 0.001); 16 Hz: before hemodialysis (W = 33, p < 0.001), after hemodialysis (W = 28, p < 0.001); 32 Hz: before hemodialysis (W = 38, p < 0.001), after hemodialysis (W = 5, p < 0.001); 64 Hz: before hemodialysis (W = 71, p = 0.014), after hemodialysis (W = 32, p < 0.001)).

Speech Perception in Noise

Table 2 shows the mean SNR-50 for participants before and after hemodialysis. The mean SNR-50 of participants obtained after hemodialysis was better compared to the SNR-50 obtained before hemodialysis. To investigate if the mean SNR-50 is significantly between before and after hemodialysis conditions, paired samples “t” test was carried out. It showed a significant effect of hemodialysis on the mean SNR-50 (t = 3.778, p < 0.001) among individuals with CKD. These findings suggest that speech perception in noise abilities of individuals with CKD is better after hemodialysis.

Relationship between Speech Perception in Noise and Temporal and Spectral Processing

Pearson’s correlation analysis was conducted to investigate the relationship between SNR-50 and temporal and spectral processing abilities. Results showed a significant positive correlation between SNR-50 and amplitude-modulation detection threshold for modulation rates 16 Hz (rho = 0.406, p = 0.044) and 32 Hz (rho = 0.466, p = 0.019) of 500 Hz carrier tone and 8 Hz (rho = 0.456, p = 0.022) of 4,000 Hz carrier tone before hemodialysis. After hemodialysis a significant positive correlation was found between SNR-50 and amplitude-modulation detection threshold for modulation rates 8 Hz (r = 0.455, p = 0.022) and 16 Hz (r = 0.625, p < 0.001), 32 Hz (r = 0.53, p = 0.006) of 500 Hz carrier tone. Further, a significant negative correlation was found between SNR-50 and SRDT before hemodialysis (rho = −0.799, p < 0.001) and after hemodialysis (r = −0.531, p = 0.006). In addition, weak correlation was observed between SNR-50 and GDT before hemodialysis (r = 0.386, p = 0.057) and after hemodialysis (r = 0.262, p = 0.206); however, it was not statistically significant. These findings suggest that speech perception in noise abilities is better among individuals with superior temporal and spectral processing abilities. Figure 1 shows the scatterplot showing relationship between SNR-50 and amplitude-modulation detection threshold across modulation rates for 500 Hz and 4,000 Hz carrier tone. Figure 2 shows the scatterplot showing relationship between SNR-50 and GDT and SNR-50 and SRDT.

Fig. 1.

a-h Scatterplot showing relationship between SNR-50 and amplitude-modulation detection threshold across modulation rates for 500 Hz and 4,000 Hz carrier tone before hemodialysis (unfilled circles – black) and after hemodialysis (filled circles – gray).

Fig. 1.

a-h Scatterplot showing relationship between SNR-50 and amplitude-modulation detection threshold across modulation rates for 500 Hz and 4,000 Hz carrier tone before hemodialysis (unfilled circles – black) and after hemodialysis (filled circles – gray).

Close modal
Fig. 2.

a, b Scatterplot showing relationship between SNR-50 and GDT and SNR-50 and SRDT before hemodialysis (unfilled circles – black) and after hemodialysis (filled circles – gray).

Fig. 2.

a, b Scatterplot showing relationship between SNR-50 and GDT and SNR-50 and SRDT before hemodialysis (unfilled circles – black) and after hemodialysis (filled circles – gray).

Close modal

The present study investigated the effect of hemodialysis on spectral processing, temporal processing, and speech perception in noise abilities among individuals with CKD. Findings of the present study showed, the mean SRDT, GDT, amplitude-modulation detection threshold, and SNR-50 of individuals with CKD were poorer compared to thresholds of individuals with no known CKD reported in literature by several investigations [Moore and Glasberg, 2001; Kumar and Sangamanatha, 2011; Nambi et al., 2016; Kumar et al., 2021; Jain et al., 2022]. The poorer auditory processing and speech perception in noise among individuals with CKD have been attributed to metabolic changes in the inner ear, uremic neuropathy, exposure to ototoxic medications, and poorer cognitive abilities [Boettcher and Salvi, 1991; Gates and Mills, 2005; Jain et al., 2022]. Currently, there is a lack of evidence to suggest that metabolic changes in the inner ear due to CKD cause auditory processing deficits. But, studies involving elderly adults have shown that metabolic changes in the inner ear due to aging could affect auditory processing abilities [Gates and Mills, 2005]. Uremic toxins accumulated in the body of individuals with CKD are known to cause uremic neuropathy. Several studies have documented abnormalities in the findings of ABR among individuals with CKD [Gierek et al., 2002; Lara-Sánchez et al., 2020], suggesting an involvement of retrocochlear pathways. Thus, poorer auditory processing in individuals with CKD could be due to the involvement of retrocochlear pathways. Ototoxic drugs cause damage to the inner ear; the pathophysiological changes in the auditory system due to ototoxicity could also affect the auditory processing abilities [Boettcher and Salvi, 1991].

The present study showed an improvement for the mean SRDT, GDT, amplitude-modulation detection threshold across modulation rates, and SNR-50 after hemodialysis among individuals with CKD. Further, the mean thresholds found in the present study among individuals with CKD after hemodialysis were comparable to thresholds reported in literature [Kumar et al., 2021]. The superior SNR-50 after hemodialysis in individuals with CKD could be attributed to improved spectral processing and temporal processing abilities after hemodialysis. Several studies have reported a moderate to strong relationship between speech perception and auditory processing [Drullman, 1995; Narne et al., 2015; Nambi et al., 2016; Kumar et al., 2021]. The improvement in temporal and spectral processing after hemodialysis could be explained in relation to findings of studies investigating the short-term effects of hemodialysis on the ABR in patients with CKD. Several studies have reported an improvement for latency of peaks of the ABR (i.e., shorter latency) after hemodialysis in individuals with CKD [Rossini et al., 1984; Pratt et al., 1986; Magliulo et al., 1987; Niedzielska et al., 1999; Aspris et al., 2008]. These findings suggest that hemodialysis could improve the neural functioning in the central auditory pathway among individuals with CKD. The enhanced neural functioning could improve coding of sound in the auditory pathway, resulting in superior temporal and spectral processing abilities among individuals with CKD.

The present study revealed poorer spectral processing, temporal processing, and speech perception in noise abilities in individuals with CKD, consistent with finding of earlier investigations. After hemodialysis, the spectral processing, temporal processing, and speech perception in noise were improved compared to before hemodialysis. Finally, the present study documents the short-term effects of hemodialysis on speech perception in noise and auditory processing in individuals with CKD undergoing hemodialysis.

This study protocol was reviewed and approved by Institutional Ethics Committee at Kasturba Medical College Mangalore, approval number [IECKMCMLR-01-14/12]. Written informed consent was obtained from participants to participate in the study.

The authors have no conflicts of interest to declare.

The authors received no financial support for the research of this article.

Conceptualization and methodology: Kaushlendra Kumar and Livingston Sengolraj. Data curation, supervision, and resources: Kaushlendra Kumar. Formal analysis: Kaushlendra Kumar and Mohan Kumar Kalaiah. Funding acquisition: NA. Investigation, software, and project administration: Livingston Sengolraj. Validation, writing-original draft, and visualization: Mohan Kumar Kalaiah. Writing-review and editing and approval of final manuscript: all authors.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.

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