Disertasi

ndeks massa bebas lemak dan fungsi otot sebagai parameter status nutrisi penderita penyakit ginjal kronik non dialisis stadium 3, 4 dan 5. = Fat free mass-index and muscle function as parameter for nutritional status in non-dialysis chronic kidney disease patients at stage 3, 4 and 5.

Pendahuluan. Insidens dan prevalensi penyakit ginjal kronik (PGK) meningkat dari tahun ke tahun baik di negara maju ataupun sedang berkembang. Malnutrisi energi protein (MEP) sering dijumpai pada penderita PGK dengan dialisis (PGK-D) ataupun sebelum mendapat terapi dialisis (PGK-ND). Malnutrisi energi protein pada PGK-ND dapat menurunkan kualitas hidup, meningkatkan morbiditas dan mortalitas serta merupakan prediktor yang kuat terhadap survival penderita PGK-D di kemudian hari. Tujuan penelitian untuk memperoleh parameter komposisi tubuh dan fungsi otot yang dapat mendeteksi kecenderungan terjadinya MEP pada penderita PGK-ND. Metode. Penelitian dilakukan di Bagian Penyakit Dalam RS Sumber Waras, RS PG!. Cikini, RS Islam Jakarta dan Universitas Tarumanagara -dengan rancangan cross sectional. Subyek penelitian: 45 penderita PGK-ND (30 laki-Iaki, 15 perempuan) dan 45 subyek kontrol yang disepadankan jenis kelamin, usia, (PGK-ND 48,2 ± 7,3 tahun, kontrol47,7 ± 6,2 tahun) tinggi badan (PGK-ND 159,4 ± 7,5 cm, kontrol 160,6 ± 7,6 cm) dan indeks massa tubuh (IMT) (PGK-ND 22,4 ± 3,4 kg/nr', kontrol22,S ± 3,1 kg/rrr'), Status nutrisi dikelompokkan dalam status nutrisi kurang, normal dan lebih berdasarkan IMT, WHO, 1995. Pada penderita dan subyek kontrol dilakukan penilaian asupan nutrisi (tanya ulang 2 X 24jam dan pencatatan asupan makanan), pemeriksaan biokimiawi (darah dan urin), pengukuran komposisi tubuh (antropometri dan Bioelectric impedance analysis, BIA). dan fungsi otot (kekuatan genggam tangan). Hasil. Penderita dan subyek kontrol didapatkan 7 (15,6%) status nutrisi kurang, 28 (62,2%) normal dan 10 (22,2%) lebih. Rerata laju filtrasi glomerulus penderita PGK-ND sebesar 19,3 ± 1,7 mLimenll,73m2, 13 (28,9%) penderita stadium 3, 17 (37,8%) stadium 4 dan 15 (33,3%) stadium 5. Konsentrasi albumin, prealbumin dan insulin like growth factor-l (IGF-l) penderita PGK-ND tidak berbeda bermakna berdasarkan status nutrisi dan stadium PGK. Konsentrasi transferin didapatkan lebih tinggi bermakna pada penderita PGK-ND status nutrisi lebih dibandingkan dengan status nutrisi kurang dan normal. Konsentrasi C reactive protein (CRP) lebih tinggi bermakna pad a penderita PGK-ND status nutrisi kurang dibandingkan dengan status nutrisi baik. Derajat asidosis metabolik (konsentrasi HC03) penderita PGK-ND tidak berbeda berdasarkan status nutrisi dan stadium PGK. Asupan nutrisi penderita tidak berbeda bermakna berdasarkan status nutrisi dan stadium PGK. Secara antropometri massa bebas lemak (MBL), indeks-MBL (I-MBL), massa lemak (ML) dan persen ML penderita PGK-ND tidak berbeda bermakna dengan subyek kontrol. Berdasarkan BIA didapatkan MBL, dan I-MBL, persen ML penderita PGK-ND lebih tinggi bermakna dibandingkan subyek kontrol (p < 0,05). Massa bebas lemak (MBL), I-MBL dan ML penderita PGK-ND berbeda bermakna antara ketiga status nutrisi (p < 0,001). Nilai MBL, I-MBL dan ML mempunyai linearitas dengan klasifikasi status nutrisi berdasarkan uji trend analysis. Massa bebas lemak dan I-MBL berkorelasi dengan IMT. Massa bebas lemak, I-MBL, ML dan persen ML PGK-ND tidak berbeda bermakna di antara ketiga stadium PGK. Status hidrasi penderita PGK-ND tidak berbeda dengan subyek kontrol dan berdasarkan status nutrisi serta stadium PGK. Status hidrasi penderita PGK-ND dan subyek kontrol dalam keadaan normal. Kekuatan genggam tangan (KGT) penderita lebih rendah bermakna dibandingkan dengan kontrol, dan KGT penderita dengan status nutrisi kurang lebih rendah bermakna dibandingkan dengan status nutrisi baik. Kekuatan genggam tangan mempunyai korelasi dengan I-MBL dan IMT. Terdapat kesesuaian yang baik antara 1- MBL dan KGT dengan IMT untuk penilaian status nutrisi penderita PGK-ND. Dengan uji Receiver Operating Curve didapatkan titik potong I-MBL sebesar 14,23 kg/rrr' dan titik potong KGT sebesar 9,7 kg untuk membedakan status nutrisi kurang dan baik. Kesimpulan. Penelitian ini menunjukkan protein viseral (albumin, prealbumin, transferin dan insulin like growth factor-I) merupakan parameter status nutrisi yang lemah untuk penderita PGK-ND. Indeks massa tubuh mempunyai korelasi positif dengan I-MBL dan KGT. Indeks-MBL dan KGT dapat membedakan derajat status nutrisi penderita PGK-ND stadium 3, 4 dan 5, dan dapat digunakan sebagai prediktor untuk skrining status nutrisi pada penderita PGK-ND.
Kata kunci: Penyakit ginjal kronik non dialisis, malnutrisi energi protein, komposisi tubuh, massa bebas lemak, indeks massa bebas lemak, kekuatan genggam tangan.



Background. The incidence and prevalence of chronic kidney disease (CKD) is increasing year by year in developed as well as developing countries. Protein energy malnutrition (PEM) often occurs in CKD patients with dialysis (D-CKD) or without dialysis therapy (non dialysis-CKD). This condition lower the quality of lite and increase the morbidity and mortality rate. It also serves as good predictor for the future survival rate of D-CKD patients. The aim of this study is to obtain body composition and muscle function parameters for early detection of PEM in non dialysis CKD (ND-CKD) patients. Methodology.The study was carried out in Internal Departments of Sumber Waras, PGI Cikini and Islam Jakarta hospitals, and Tarumanagara University using the "cross sectional" design. The subjects of the study: 45 ND-CKD patients (30 males and 15 females) and 45 controls matched for age (48.2 ± 7.3 years vs, 47.7 ± 6.2 years), gender, height (159.4 ±7.5 cm vs 160.6 ± 7.6 cm) and body mass index (BMI) (22.4 ± 3.4 kg/m" vs 22.5 ± 3 kg/nr'). The nutritional status of both the patients and controls were classified based on BMI (WHO, 1995) into low, normal and high nutritional status groups. Food intake assessment (two days recall and food record), biochemistry tests (blood and urine), body composition measurement (anthropometric and bioelectric impedance analysis) and muscle function test (handgrip strength) were also performed on both patients and controls. Results. Each patients and controls group consisted of7, 28, and 10 subjects with low, normal and high nutritional status respectively. The ND-CKD patients with a mean glomerular filtration rate of 19.3 ± 1.7 mUminJ1.73 m2, consisted of 13 patients (28.9%) stage 3, 17 patients (37.85%) stages 4 and 15 patients (33.3%) stage 5. The albumin, pre-albumin and insulin like growth factor-l (lGF-l) concentrations in the ND-CKD patients were the same regardless of their nutritional status classification and CKD stages. Transferin concentration was higher of ND-CKD overweight patients than their underweight and normal nutritional status. C reactive protein (CRP) concentration was found to be significantly higher in ND-CKD patients with low nutritional status than those in normal nutritional status. The degree of metabolic acidosis (HC03 concentration) in ND-CKD patients did not differ among the three nutritional status groups and CKD stages. The food intake of the patients showed no significant difference with their nutritional status and CKD stages. Fat free mass (FFM), FFM-index (FFM-I) and percentage of fat mass (FM percentage) in patients measured by anthropometric technique showed no significant difference with controls. Using the BrA method, FFM, FFM-I and FM percentage were significant higher in the ND-CKD patients compared to the controls (p < 0,05). Significant difference in FFM, FFM-I, FM and FM percentage was observed between the patients with different nutritional status. (p < 0,001). Trend analysis statistical test showed that there is linear correlation of FFM, FFM-I and FM with nutritional status classification. FFM, FFM-I, FM and FM percentage in ND-CKD patients were not significantly different between the three stages of CKD. The hydration status of the ND-CKD showed no significant difference with the controls, as well as with nutritional status classification and CKD stages. Patients and controls were under normal hydration status. The handgrip strength (HGS) of the ND-CKD patients were significantly lower than the controls and the HGS of the ND-CKD low nutritional status group was significantly lower than of the normal nutritional status. There was positive correlation between HGS with FFM-I and BMI. Moreover, there was an acceptable degree of agreement of BMI with FFM-I and HGS for nutritional assessment in ND- CKD patients. The Receiver Operating Curve test showed the cut off points of FFM-I and HGS 14.23 kg/m" and 9.7 kg respectively to differentiate undernutrition and normal nutritional status in ND-CKD patients. Conclusion. This study showed that visceral proteins (albumin, pre-albumin, transferin and insulin like growth factor-I) were weak parameters for nutritional status assessment in ND-CKD patients. Body mass index showed good correlation with FFM-I and HGS. Fat free mass index and HGS can be used to differentiate degrees of nutritional status in stage 3, 4 and 5 ND-CKD patients and considered predictor parameters for nutritional status screening in ND-CKD patients.
Key words : Non dialysis chronic kidney disease, Protein energy malnutrition, body composition, fat free mass, fat free mass index, handgrip strength.