Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241124EnglishN2020February28HealthcareBlind Helicobacter pylori Treatment in Dyspeptics in a High Prevalence Area English0107Wadzani GashauEnglish Aisha Shehu AdamuEnglishBackground: The initial management of dyspepsia is shifting away from the invasive endoscopic biopsy procedure to identify H. pylori before eradication treatment. A test-and-treat strategy is firmly in place, but choices can be limited in resource constrained environments. Objective: To investigate the short term effect of blind eradication therapy in management of dyspeptic patients prior to knowledge of H. pylori infection status by serology and histology. Patients: A cross sectional study of 125 consecutive patients presenting at a tertiary facility with dyspepsia were screened for other diseases and then offered blind triple H. pylori eradication therapy. Methods: Participants underwent clinical evaluation and completion of a structured questionnaire eliciting sociodemographic, smoking and drinking habits and drug history. Stored sera were tested for liver transaminases, total protein, albumin, creatinine, urea, Hepatitis B surface antigen, Hepatitis C virus antibody and H. pylori IgG antibody by ELISA at the end of recruitment, while stool microscopy, occult blood test and abdominal ultrasound scan were done before upper gastrointestinal endoscopy, where antral biopsy specimens obtained were processed for H. pylori identification and histological assessment. Patients received oral amoxicillin 1g and clarithromycin 500mg twice daily or metronidazole 400mg three times daily (in place of clarithromycin) and omeprazole 20mg twice daily for fourteen days andcame for follow-up at two and four weeks for assessment of treatment response. Data were entered into a computer and analysed using SPSS Version 16. Descriptive statistics, Chi- square test with Yates correction, t-test, ANOVA and the Cochran-Mantel Haenszel test to compare proportions of treatment success were used. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were determined. P values < 0.05 were considered significant. Results: All patients (125) completed the study, 76 (60.8%) were females and the mean age of subjects was 35.3 ± 12.70 years (range 18 – 84); 74.4% of respondents were < 42years of age and 90% < 55 years. H. pylori were detected by histology in 100 (80.0%) patients, 99 of whom were among the 117 (93.6%) positive by serology (Sensitivity 99%, PPV 84.6%, efficiency 84.9%). Endoscopy was normal in 5% of patients and gastritis 39.5%, oesophagitis 27.7%, and duodenitis 22.7%. The relationship between chronic gastritis inflammatory activity and H. pylori infection status was highly significant. Chi square X2 = 24.33 p= 0.000001; Yates correction X2 = 20.04 p=0.000008. Symptom improvement was highly significant at both 2 and 4 weeks from baseline and between the two visits. (p=.000). Cochran-Mantel Haenszel test to compare proportions of treatment success by H. pylori status was highly significant (Q=112.067 p=.000) Conclusion: On a short term basis, blind empirical H. pylori eradication therapy is effective in the management of dyspeptic patients in a high prevalence area and can obviate the need for testing before treatment. Serology concurred very well with histology as a method of infection identification. EnglishDyspepsia, Helicobacter pylori, High prevalence, Empirical treatment, OutcomeIntroduction Dyspepsia is a common and often bothersome symptom complex related to the upper gastrointestinal tract and has an extensive differential diagnosis including gastroduodenal, oesophageal and biliary disorders among others. At presentation, patient symptoms tend to be multiple and do not reliably predict underlying causes or endoscopic findings. Pooled data from 99 studies put the global prevalence in the community at 20.8% with North European and American studies at 22% and Africa and South America, 35.7% and 37.7% respectively.1 In Nigeria, a prevalence of 26% in a community-based study in northeastern2 and 45% in the middle belt regions were noted over the same period.3 Chronic or recurrent dyspeptic symptoms have been reported in 20-30% of people in Britain4,5 and the incidence of the first time symptoms at 1% annually in the community.6 The wide variation in prevalence persists even when same diagnostic criteria are used.1 Dyspepsia increases with age2,3 and is commoner in smokers, NSAID users and in females.1 In the past, the need to identify the underlying cause of dyspepsia led to wide spread use of endoscopy where in the United Kingdom for instance, more than 1% of the population underwent gastroscopy each year.7 However, despite its high degree of diagnostic accuracy, qualitative systematic review does not support its effectiveness in managing dyspeptics, thus making generalized usage unrealistic.8 With the identification of Helicobacter pylori (H. pylori) as the most important aetiological agent of chronic active gastritis and peptic ulcer disease, and epidemiological causal relationship to gastric cancer and classification as a group 1 carcinogen9 a lot of progress has been made in detecting this organism in non-invasive ways in place of endoscopy in patients with upper gastrointestinal symptoms with the assurance that the subgroup with underlying ulcer disease could be cured and the risk of developing actual ulcer disease10,11gastric cancer and lymphoma12 removed in non-ulcer dyspepsia. H. pylori as the most common chronic bacterial infection in humans13 affects 4.4 billion people worldwide according to pooled data from 62 countries.14 In Northern Europe and America, approximately one third of the population is affected15 but prevalence varies amongst ethnic groups, while more than 50% are infected15 in Eastern Europe, South America and Asia, and in Africa, 70.1%.14 Reported pooled prevalence of 87.7% is highest in Nigeria14 where rates in north are 58%, 69% and 91% in children 0.05). This differential age prevalence in our cohort supports the suggestion that serology can be used for screening young dyspeptics, as inaccurate test results are said to be more common in the elderly.33 Epigastric pain and tenderness as previously documented in the same community34 as the commonest clinical features in the index population is in consonance with a report from Zaria35 unlike nocturnal pain in Kano subjects.18 Patients who were H. pylori positive had more symptoms than those without, but this did not achieve statistical significance. While data from multicenter studies have suggested that age should be discountenanced in favour of alarm symptoms due to its poor predictability of underlying pathology36 neither age nor alarm symptoms were predictive of underlying pathology in this study group which further supports the NICE recommendation that all dyspeptic patients without alarm symptoms irrespective of age should initially be managed without endoscopy.37 As previously documented in this population, antral gastritis (37.6%) remains the most frequent finding38 as against gastritis with duodenitis in some series.17,35  We found no endoscopic abnormalities in 5% of patients who belonged to the H. pylori negative group, which agrees with the 6% from Ife.39 Our findings support the report that systematic review of models using risk factors, history, and symptoms did not reliably distinguish between functional dyspepsia and organic disease40or severity of gastritis41 as all our cases could be categorized as non-ulcer dyspepsia, unlike a study in northwestern Nigeria which reported equal rates of non-ulcer dyspepsia and peptic ulcer disease (34.5% and 35% respectively), distantly followed by gastritis (9.9%).18 As previously highlighted as the African enigma, peptic ulceration is still lower in this population compared to the rate of H. pylori infection.38 This is attributed to the strains of H. pylori42 and the lower basal acid and maximum acid outputs in asymptomatic African controls43 compared to westerners, possibly due to the less pathogenic effect of H. pylori infection acquired in childhood than in adulthood as suggested by Graham.44 Histology to a significant extent corroborated the validity of serology in detecting H. pylori in our patients not minding the possibility that prior antibiotic treatment or inadequate biopsies could have reduced the detection rate. The degree of histological activity was more in those positive by either serology or histology or both attaining high statistical significance (p < 0.000001), thus comparable with studies utilizing 13C levels where the degree of histological gastritis corresponded to the number of H. pylori organisms.45 Giardiasis which can be chronic and may not produce diarrhoea, and responds to metronidazole46 has been suggested as an important differential in dyspepsia in Scottish children47 was not detected in any of our patients. Abdominal ultrasound scan is still important in evaluating dyspepsia as demonstrated in two patients positive for H. pylori, yet had gallbladder disease. The reported presence of both HBV (13%) and HCV (6.8%) and dual (1.6%) infections occurring exclusively in the H. pylori serology positive subjects may just be a reflection of the trend in the population48,49 as there was no significant statistical relationship to the status of infection. All the serologically positive patients at 2 weeks after H. pylori eradication therapy indicated improvement in symptoms with 5.1% showing much improvement. By 4 weeks, an even higher proportion (88.9%) had much improved (p=.000) which is the expected outcome of specific therapy. Conversely, in the H. pylori negative group, all patients who reported initial improvement at 2 weeks had a decline in outcome at 4 weeks. The 6 subjects (75%) who reported much improvement declined to “improved” and the other 2 (25%) reverted to the “same” (status quo ante). This is the anticipated response when eradication therapy is used in non-H. pylori dyspepsia. While this inferior response in the uninfected group supports the view that the empirical use of antibiotics without the confirmation of H. pylori is not recommended50 the overwhelming (98.4%) response in our patients, (83.2% much improved and 15.2% improved) at 4 weeks strongly supports the empirical use of antibiotics; more so, they all received eradication therapy before their infection status were known. Only 2 (1.6%) of 125 patients at 4 weeks that reverted to status quo ante can be assumed to have inappropriately received eradication therapy. Those who benefitted included patients with oesophagitis and reflux symptoms (gastric and biliary) though the beneficial effect of PPI related acid suppression in this group cannot be ruled out considering the short period of follow up. If we depended solely on the gold standard test, the relief reported by 23 patients (17 histological and 6 of 8 serological) would have been denied them, thus supporting the suggestion that a response to eradication of H. pylori in 5–10% of all patients with non-ulcer dyspepsia would make screening and treatment for H. pylori a bene?cial option, irrespective of any other potential bene?ts.51 Limitations of the study Our study showed that all our patients could initially be started on eradication therapy and other approaches used if some showed no improvement, however, concerns still remain because of the possibility of delayed diagnosis of gastric cancer, 87 cases of which were reported in our hospital52 a referral tertiary institution over a 16-year period. Reports from other parts of Nigeria also indicate that gastric malignancies have been seen in the third and fourth decades in patients though they presented with complicated dyspeptic symptoms some lasting 12 months.53 Even though endoscopy in all our patients removed intervention bias as may be seen in comparative studies of test-and-treat versus endoscopy and treatment54 the possibility of patient satisfaction after detailed explanation of the procedure may have positively impacted treatment outcome in the short term. In light of the reported resistance issues, it must be emphasized that the triple therapy we employed in our patients may no longer be appropriate as the antibiotic stewardship in Nigeria is suboptimal due to the high rate of over-the-counter availability of prescription-only medicines including antibiotics and antibiotic-containing triple therapy ulcer drugs.55,56 The fear of empirical treatment increasing the problem of community-acquired antimicrobial resistance in view of the rather high inappropriate prescription rates in primary care practice in some countries57 can be minimized if appropriate antibiotic stewardship is embraced.57,58 Conclusion H. pylori must be viewed as an infection which requires specific eradication therapy using appropriate regimen where susceptibility testing is available in dyspepsia management in view of the widespread resistance to clarithromycin and metronidazole reported in several regions of the world. Where it is not as is often the practice among gastroenterologists, empirical therapy must be based on usage of quadruple therapy, local bacterial resistance patterns and recommendations, and drug availability. While it has been advocated that even in high prevalence areas there should be testing before treatment for H. pylori our study has conclusively shown that in high prevalence resource limited areas, blind H. pylori eradication is effective and feasible and can obviate the need for specific methods of H. pylori detection and endoscopy in most of our patients. Therefore, the suggested cost-effective approach to dyspepsia management in our population is: treat to eradicate, and if no improvement; give empirical PPIs, and lastly administer endoscopy as appropriate. We recognize however, that the management of dyspepsia should vary in different countries depending on the incidence of H. pylori infection and gastric cancer rates as cancers are commoner in some regions than others. Conflict of Interest The authors have no conflict of interest to declare Funding The study was partly funded by the University of Maiduguri Teaching Hospital, Maiduguri as grant for Dr. Aisha S. Adamu’s fellowship dissertation preparation. Northeastern Nigeria remains a high prevalence area for H. pylori infection Serology concurred very well with histology as a method of infection identification. Blind H. pylori eradication therapy was effective in the management of dyspeptic patients The need for testing before treatment can be obviated in most of our patients Glossary of Abbreviations ANOVA – Analysis of variance HBV – Hepatitis B virus HCV – Hepatitis C virus IgG – Immunoglobulin G MALT – Mucosa associated lymphoid tissue NICE – National Institute for Health and Care Excellence NPV – Negative predictive value PPV – Positive predictive value SPSS – Statistical Package for Social Sciences UMTH – University of Maiduguri Teaching Hospital Englishhttp://ijcrr.com/abstract.php?article_id=2653http://ijcrr.com/article_html.php?did=26531. Ford AC, Marwaha A, Sood R, Moayyedi P. Global prevalence of, and risk factors for uninvestigated dyspepsia: a meta-analysis. Gut 2015; 64(7): 1049-1057 2. Holcombe C, Omotara BA, Padonu MK et al. The prevalence of symptoms of dyspepsia in Nigeria. A random community based study.  Trop Geogr Med 1991; 43; 209-214 3. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241124EnglishN2020February28HealthcareStudy of Prevelance and Pattern of Senserineural Hearing Impairment in Stage 5 Chronic Kidney Disease Patients on Haemodialysis- at a Tertiary Health Care Setup in India English0813Poulomi SahaEnglish Kapil MondalEnglishBackground: In patients with established CKD, multiple risk factors have been hypothesized to cause senserineural hearing loss. There is high rise in the prevalence of CKD in India due to rise in conditions such as diabetes and hypertension. Aim of the Study: To identify the pattern of sensorineural hearing loss (SNHL) in stage 5 CKD patients on haemodialysis and to study the association between haemodialysis and degree of hearing changes. Study Design: Case control, observational, analytical study. Method: In this case control study 500 stage-5 Chronic kidney disease adult patients on haemodialysis and 500 age and gender-matched healthy individuals were included over the period of 3 years. Upper age limit was restricted till 55 years to avoid presbyacusis. After base line investigations, they were subjected for all cases and controls were subjected otoscopic examination and hearing assessment using standard pure tone audiometry. Descriptive statistical analysis has been carried out in this study. Result: In CKD group, 96.5 % patients (5 patients had natural death) suffered from hearing loss and 3.5%(17) patients had normal hearing. In control group, 31.2% suffered from Sensorineural hearing loss and 68.2%(343) have no hearing loss . Among the Stage 5 CKD group, 11.9% had mild SN hearing loss, 14.2% had moderate sensorineural hearing loss,14.8% had moderately severe sensorineural hearing loss, 25.7% had severe SNHL, and 33.2% had profound SNHL. In the control group, 9% had mild SNHL, 7.6% had moderate SNHL, 7.1% had moderately severe SNHL,5.4% had severe SNHL and 2.2% had profound SNHL. Deterioration of hearing acuity occurred in 62% of the patients at the end of follow-up and 12.4% of the participants showed improvement in hearing acuity. 25.6% patients showed no improvement. Conclusion: Our finding in present study is that CKD patients with hearing loss received significantly lesser haemodialysis sessions is interesting as it suggests a possible beneficial association between increasing number of dialysis sessions and hearing loss. EnglishHaemodialysis, Hearing loss, Sensori-neural hearing lossINTRODUCTION Chronic kidney disease (CKD) refers to a gradual and usually irreversible reduction of glomerular filtration rate (GFR) which can be caused by trauma, genetic disorders, infections and effect of drugs that are toxic to the kidneys. Other disease conditions such as diabetes and hypertension increase the risk of an individual developing kidney failure. About 10% of the world’s population is affected by various forms of kidney disease making it a global public health challenge. The association between chronic kidney disease (CKD) and hearing impairment was first reported more than 80 years ago by Alport , who described a case of familial kidney disease related to hearing impairment. The etiopathogenetic mechanisms of Sensorineural hearing loss in CKD is due to osmotic alteration resulting in loss of hair cells, collapse of the endolymphatic space, edema and atrophy of specialized auditory cells and in some, complications of  hemodialysis itself . Because of certain anatomic, physiological  and ultrastructural similarities between the stria vascularis of the inner ear and basement membranes of glomeruli and evidence for similar antigenicity of the cochlea and kidney, may explain this association of CKD and SN loss can be explained  to some extent. In patients with established CKD, multiple risk factors have been hypothesized to cause hearing loss such as use of hypertension ototoxic drugs, hypertension, nephrotoxic drugs, electrolyte disturbances, diabetes, particularly in association with hypertension and hemodialysis itself   and age of patient have been implicated in various studies. Despite the multitude of studies regarding hearing loss in CKD, some dark domains still persists regarding the role of haemodialysis and duration of disease. There is high rise in the prevalence of CKD in India due to rise in conditions such as diabetes and hypertension. Comparatively, hearing loss has been found to be more prevalent among CKD patients than the general population in different parts of the world ranging from  28% to 67% have been recorded in similar studies. OBJECTIVE To determine the  pattern of sensorineural hearing loss (SNHL)   in CKD patients on haemodialysis attending Medicine Department . To study the association between haemodialysis   and degree of hearing changes. STUDY DESIGN Case control, observational, analytical study MATERIALS AND METHODS Study area: Department of MEDICINE, Heamodialysis unit, Mursidabad Medical College, Berhampore. West Bengal. Study period: November, 2016 – November, 2019. Ethical clearance: Institutional ethics committee clearance was taken prior to the commencement of the study. Study sample   Cases-500 CKD stage 5 (End Stage Renal Disease, ESRD) patients aged 18 to 50 years  who have undergone at least one session of haemodialysis. Particularly, age was limited to 50 years for purposes of excluding presence of   presbyacusis.  CKD patients with conductive hearing loss and syndromic etiologies of CKD in which hearing loss is a known component, were excluded from this study. Controls: As control group of 500, age and gender-matched healthy individuals were included in this study. These are the individuals without any history of ototoxic medications within the last three months, as well as those with no chronic diseases such as diabetes, hypertension, renal impairment and rheumatoid diseases, without  family history of hearing loss, no  prolonged noise exposure, no history of otosclerosis, other ear diseases and ear surgery. METHODOLOGY From all cases and controls documented informed consent was obtained All patients were investigated using standard performa containing details of age, gender, chronic illness, hypertension, diabetic status and past or recent administration of ototoxic medications. Duration of  stage 5 chronic kidney disease and total number of haemoldialysis sessions obtained were documented. Both case and control groups were subjected to have complete haemogram, coagulogram, fasting and post prandial blood sugar, serum LFT and RFT, electrolytes ,viral serology of HIV 1, HIV 2 and HBs Ag.  All CKD patients and controls were subjected otoscopic examination and hearing assessment using standard pure tone audiometry at 250, 500, 1000, 2000, 3000, 6000, 7000, and 8000 Hz. As bone conduction threshold is limited upto 4000Hz,so the audiometric recordings  ≥4000 Hz  were done by air conduction  testing  only because  High frequency sensorineural hearing  recording by air conduction mode is unaffected by middle ear effusion. An average of the threshold levels of >26 db was considered as abnormal. A hearing loss of 26–40 db was classified as mild, 41–55 db as moderate, 56–70 as moderately severe, 71–90 as severe, and >90 db as profound hearing loss. Air and bone conduction thresholds were compared to identify the type and degree of hearing loss. Descriptive statistical analysis has been carried out in this study. Results on continuous measurements are presented on mean standard deviation (minimum  and maximum) and results on categorical measurements are presented in number (%). Chi square test is used to compare the difference in proportions. The significance is assessed at 5% level of significance. Differences were considered significant if the p value was less than 0.05.   Total 500 stage 5 chronic kidney disease patients were studied to measure the burden of sensorineural hearing loss in them. This was a case-control study. Five CKD   patients succumbed to death  in the course of the disease. They were excluded from the study. In the control group too one patient expired due to cerebrovascular accident (CVA).   After exclusion and inclusion criteria, among five hundred CRF control patients treated with hemodialysis, 357 were males and 143 females. Mean age in the case group was 51.9 for males and 42.5 for females. Duration of illness was 1–5 years (mean 3.2). In control group 315 patients were  male  and 184 patients were female. Mean age in the control group was 50.3 for males and 41.2 for females. In CKD group, 96.5 % patients (478 out of 495) suffered from hearing loss and 3.5%(17) patients  had normal hearing. In control group, 31.2% (156 out of 499 patients) suffered from SN hearing loss and 68.2%(343) have no hearing loss .  Among the Stage 5 CKD group, 11.9%(57 patients) had mild SN hearing loss, 14.2% had (68 patients)had moderate SNHL(sensori-neural hearing loss),14.8%(71 patients) had moderately severe SNHL , 25.7%(123 patients) had severe SNHL, and 33.2%(159 patients) had profound SNHL. In the control group, 9% (45 people) had mild SNHL, 7.6%(38 people) had moderate SNHL,7.1% (35 people) had moderately severe SNHL,5.4% (27 people) had severe SNHL and 2.2%(11 people) had profound SNHL. 65 % Stage 5 CKD patients had high frequency(8000Hz) SNHL(62 % bilateral & 3% unilateral), 25% had mid frequency (4000Hz) SNHL (19% bilateral & 6 % unilateral) and 10 % had low or at speech frequency (500–2000 Hz) SNHL(8% bilateral & 2% unilateral). 104 patients( 20.84%)  who were on haemodialysis for less than 1 year  presented with hearing loss (hearing threshold above 20 dB). 215 patients(43.08%) presented hearing loss who were on haemodialysis for more than 1 year but less than 3 years. The patients who were on haemodialysis for more than 3 years but less than 5 years were 135(27.2 %) in number.  50 patients (10.1%) who were on haemodialysis for more than 5 years presented with hearing loss. The dominant hearing loss was obvious at high frequencies. Deterioration of hearing acuity occurred in 62% of the patients at the end of follow-up and 12.4% of the participants showed improvement in hearing acuity.25.6% patients showed no improvement. Among CKD patients with hearing loss, the majority of the patients, 215 patients received 151 to 450 sessions. 104 patients received less than 150 sessions.135 patients received 451-750 sessions. 50 patients received more than 750 sessions. DISCUSSION A number of studies conducted in India and abroad have documented and published higher incidence of hearing loss among children and adults with chronic renal disease. The prevalence of   hearing loss in CRF   greatly varies  in different countries. In India, it was reported to be 63.5%, in Nigeria 67% , in Iran 46% , and in Croatia 63.6% . Earlier studies showed higher prevalence of hearing loss even upto 70%–75%. This variation could be due to differences in the age of patients, methods of assessment of hearing loss, or duration of CRF and  hemodialysis. The exact pathophysiology between hearing impairment and CKD is addressed in various ways. Over many years’, research have  linked  CRF and hearing loss in patients with rare diseases like mitochondrial myopathy, lactic acidosis, stroke, Alport syndrome  and Fabry’s disease. Electrolyte disturbances, particularly sodium, water imbalance, hypertension, Vitamin D deficiency, and elevated serum urea levels are some proposed mechanisms for hearing impairment in patients with CRF. Defects in the cationic gradient of endolymphatic fluid can adversely affect hearing .  Along with this alterations in the peripheral and central nervous system, “uremic neuropathy,” may lead to hearing impairment in CRF. Di Paolo et al reported a high incidence of nerve conduction dysfunction in patients with CRF. They found decreased conduction velocity in the sensory and motor units, with the sensory units being more compromised than the motor. Rossini et al  were unable, to arrive at a definite conclusion regarding the effect of haemodialysis on hearing in CKD. In contrast, Peyvandi et al  proposed in a recent study that prevalence and severity of  hearing loss increases with duration of CKD and haemodialysis. Ozen et al reported audiometric improvement of 20 decibel of hearing perception of chronic kidney disease patients following haemodialysis. They hypothesized that haemodialysis causes change in serum osmolarity, BUN and fluid retention  which may reverse the hearing impairment in post dialysis period. Though contradicting studies like are there questioning hearing improvement following haemodialysis. Contributory evident data to indicate beneficial role of  haemodialysis on hearing threshold in CKD patients is present in this study. Possible beneficial association between increasing number of dialysis sessions and hearing threshold improvement is documented in 12.4% patients of  chronic kidney disease because we found that chronic kidney disease  patients with hearing loss received significantly lesser haemodialysis sessions in comparison to those having higher number of  haemodialysis sessions. We concluded the hearing threshold improvement occurred due to improvement of serum osmolality following haemodialysis. Improved serum osmolality may have reverted the collapse of endolymphatic space and may have reduced the edema of  some functionally active auditory cells. Thus causing improvement of   hearing threshold to some extent. In our study deterioration of hearing   occurred in 62% of the patients at the end of follow-up. 12.4% of the participants showed improvement in hearing acuity. 25.6% patients showed no improvement. We also observed that hearing loss at high frequencies might be the most common audiometric abnormality in CKD patients, but not the typical one. This audiometric difference , that is the presence of high frequency, mid frequency and even low frequency SN loss in CKD may be due to several reasons. But typical detection of high frequency in the above studies were mostly due to small sample sizes in both studies(49 and 63 CKD patients, respectively). Secondly, the questions  were only used to access high-frequency SN loss in audiometry  in patients, possibly  not designing questionnaire for patients with  mild and moderate frequency  SN loss in conventional audiometry. So these number of studies clearly established  prevalence of hearing loss among CKD patients, but  well-designed studies with larger sample sizes were needed to adress relationships between hearing loss in CKD and haemodialysis. Also another important question that arises in this context is whether a blanket audiometric screening of all CKD patients would help identify mild hearing loss and prevent progression to severe degrees, especially if a beneficial role for haemodialysis can be definitely established in long-term prospective studies. This present study answers   both of the questions to some extent. This study found  96.5%(478 patients) of CKD patients on haemodialysis had hearing loss, considerably higher than the normal population who had 31.2% hearing loss[FIGURE: 1] . In other words, mostly all stage 5 CKD patient on haemodialysis experiences some degree of hearing impairment.  11.9%(57 patients) had mild SN hearing loss, 14.2% had (68 patients)had moderate SNHL(sensori-neural hearing loss),14.8%(71 patients) had moderately severe SNHL , 25.7%(123 patients) had severe SNHL, and 33.2%(159 patients) had profound SNHL. That is 40.5%, majority of the patients had moderately severe to severe SN loss. Hearing thresholds were abnormal in CKD patients on haemodialysis across all frequencies ranging from 250Hz to 8 kHz. SN loss was  high frequency in 65% patients, mid frequency in 25% patients and  low frequency in 10% patients [FIGURE: 2] The prevalence of hearing loss in CKD patients varies from 28 per cent to  77 per cent according to different studies. Notably, many older studies have shown higher prevalence of hearing loss, possibly due to small sample sizes. The prevalence of this study is 48.9%. The high prevalence of hearing loss at enrollment in the study reflects the significant effect of CRF on hearing function. Yet, the impact of hemodialysis on the hearing threshold after 18 months was still substantial. The hearing threshold deteriorated from 30.5 ± 15.1 dB at the start of the study to 45.2 ± 11.3 dB after 18 months, which was a highly significant difference (P < 0.001).This study also showed that CKD patients with hearing loss received [ FIGURE: 5 ] significantly fewer haemodialysis sessions compared to those without hearing loss. Our finding that CKD patients with hearing loss received significantly fewer haemodialysis sessions is interesting as it suggests a possible beneficial association between increasing number of dialysis sessions and hearing loss. Thus, it is evident that there are data to indicate contributory as well as beneficial roles for haemodialysis on hearing in CKD patients. The finding of Lasisi et al. supports this result. The role of hemodialysis in the occurrence of hearing loss among patients with CRF could be due either to changes in the fluid and electrolyte composition of endolymph or accumulation of amyloid materials in inner ear tissues. Aluminum toxicity associated with chronic dialysis may play a role in hearing loss. Nikolopoulos et al, Ozturan and Lam , Stavroulaki et al , and Pandey et al showed that auditory functions and thus hearing acuity were not affected by hemodialysis, particularly short term dialysis , or at least in the first 5 years of treatment. In contrast, other researchers reported that hearing is improved by hemodialysis. Aspris et al indicated that although there is improvement in neural auditory function following hemodialysis, it is not restored to a normal level. Gafter et al. concluded that although dialysis may have some temporary beneficial effect, the longterm effect is not assured. The acceptable  explanation of hearing improvement particularly in low frequency hearing loss is that hemodialysis promotes normalization and stabilization of hydroelectric and metabolic changes in the endolymph that were induced by CRF, leading to enhancement of neural conduction and restore hair cell function. CONCLUSION Mild sensorineural hearing impairment in CKD patients on haemodialysis is well documented in number of studies. Though this hearing loss is mostly high frequency but other emerging studies marks significant  presence of low frequency and mid frequency loss .These patients were likely to be older and had a significantly longer exposure to ototoxic drugs. Haemodialysis might have a promising effect on hearing loss in CKD patients, but further research by long-term prospective studies are required to  link common pathophysiology between kidney dysfunction and cochlear impairment to potentially modify the normal care of CKD patients of higher stages.  It should encourage clinicians to regularly question about hearing function in their preventive care protocols and  to refer all CKD patients with hearing loss to otorhinolaryngologists for evaluation and rehabilitation .  ABBREVIATION: CKD   =Chronic kidney disease CRF   =Chronic renal failure. SNHL = Senserineural hearing loss ESRD= End stage renal disease LFT=     Liver function test RFT  =  Renal function test Hz     = Hertz CVA =Cerebro vascular accident Db    =  Decibel BUN= Blood urea nitrogen. Englishhttp://ijcrr.com/abstract.php?article_id=2654http://ijcrr.com/article_html.php?did=2654 Joseph O. 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