Tesis

Determinan Variabilitas Hemoglobin pada Pasien Penyakit Ginjal Kronik yang Menjalani Hemodialisis Rutin = The Determinant of Hemoglobin Variability in Chronic Kidney Disease Patients on Hemodialysis.

Latar Belakang. Variabilitas hemoglobin (var-Hb) merupakan suatu fenomena fluktuasi kadar Hb dalam satuan waktu tertentu yang dialami oleh pasien penyakit ginjal kronik yang menjalani hemodialisis rutin (PGK-HD). Var-Hb telah diketahui sebagai prediktor independen luaran klinis buruk. Namun, faktor-faktor yang mempengaruhinya belum banyak diketahui. Tujuan. Mengetahui besaran proporsi var-Hb pada pasien PGK-HD di Indonesia dan faktor-faktor yang mempengaruhinya. Metode. Penelitian ini merupakan studi kohort prospektif yang melibatkan pasien PGK-HD berusia ≥18 tahun di Unit Hemodialisis RSCM. Faktor-faktor yang dinilai saat awal ialah kadar Hb, reticulocyte-hemoglobin equivalent (RET-He), albumin, fosfatase alkali, dan C-reactive protein (CRP) serum, serta adekuasi dialisis (Kt/V). Adanya perdarahan saluran cerna (termasuk darah samar feses), dosis erythropoietin-stimulating agent (ESA) dan zat besi, serta kejadian transfusi darah akan dicatat. Kadar Hb kemudian diperiksa setiap 4 minggu hingga 24 minggu pengamatan. Var-Hb dinilai dengan standar deviasi residual dan nilai ≥ 1,0 dianggap sebagai var-Hb tinggi. Uji hipotesis dilakukan dengan uji bivariat sesuai jenis data, dilanjutkan dengan analisis multivariat menggunakan uji regresi logistik multipel. Hasil. Sejumlah 127 subyek (rerata[SD] usia 49,06[15,1], perempuan 52%, rerata[SD] kadar Hb 9,75[1,00] g/dL) diikutsertakan dalam analisis. Proporsi subyek dengan var-Hb tinggi ialah 47,24%. Berdasarkan analisis bivariat dan multivariat, faktor yang mempengaruhi var-Hb adalah kadar RET-He (p=0,004), dosis ESA (p=0,032), dan kejadian transfusi darah (adjusted OR 6,967, IK95% 2,74-17,71; p < 0,001). Kesimpulan. Proporsi pasien PGK-HD di Indonesia yang memiliki var-Hb tinggi ialah 47,24% (IK95% 38,3-56,3%). Faktor-faktor yang mempengaruhi var-Hb ialah kadar RET-He, dosis ESA, dan kejadian transfusi darah.
Kata kunci: penyakit ginjal kronik, hemodialisis rutin, variabilitas hemoglobin, anemia renal.


Background. Hemoglobin variability (Hb-var) is a phenomenon of Hb fluctuation during a course of time that is frequently observed in chronic kidney disease on hemodialysis (CKD-HD) patients. Hb-var is now recognized as a predictor of poor clinical outcomes. However, factors that influence the Hb-var are not well understood. Objectives. This study was aimed to measure the proportion of Hb-var in CKDHD patients in Indonesia and identify factors associated. Methods. This was a prospective cohort study involving CKD-HD patients aged ≥ 18 years old in Hemodialysis Unit in RSCM. Factors identified at baseline were serum levels of Hb, reticulocyte-hemoglobin equivalent (RET-He), albumin, alkaline phosphatase, C-reactive protein (CRP), and dialysis adequacy (Kt/V). Hb level was measured every 4 weeks until 24 weeks of follow up. Any evidence of gastrointestinal bleeding (including occult blood feces), erythropoietin-stimulating agent (ESA) dosage, and blood transfusion were also noted. Hb-var was calculated as the residual standard of deviation, and value ≥ 1.0 was considered as high. Hypothesis testing was performed by bivariate analysis, then continued with multivariate analysis using multiple regression logistic test. Results. As 127 subjects (mean[SD] of age 49.06[15.1], female 52%, mean[SD] of Hb 9.75[1.00] g/dL) were included in the analysis. The proportion of subjects with high Hb-var were 47.24%. According to bivariate and multivariate analysis, factors that determined Hb-var were RET-He levels (p=0.004), ESA dosage (p=0.032), and blood transfusion (adjusted OR 6.967, 95%CI 2.74-17.71, p < 0.001). Conclusion. The proportion of CKD-HD patients in Indonesia with high Hb-var was 47.24% (95%CI 38.3-56.3%). Factors that determined Hb-var were RET-He levels, ESA dosage, and blood transfusion.
Keywords: chronic kidney disease, hemodialysis, hemoglobin variability, renal anemia.