Tesis

Korelasi Volume Flow Rate Arteri Brakialis Paska Anastomosa terhadap Maturitas Pembuatan Akses Fistula Arterivenosa Brakiosefalika pada Pasien Penyakit Ginjal Tahap Akhir dengan Diabetes Melitus = Correlation of Post-anastomous Brachial Artery Volume Flow Rate on Maturity of Brachiocephalic Arterivenous Fistula Access in End-stage Kidney Disease Patients with Diabetes Mellitus.

Latar Belakang : Evaluasi volume flow rate (VFR) draining-vein dengan USG doppler sesaat paska anastomosa menjadi upaya baru dalam memperbaiki angka kegagalan proses maturasi fistula arterivenosa (FAV), setelah diketahui batasan nilai prediktif VFR draining-vein terhadap terjadinya maturitas FAV yang dibuat, tetapi karena tingginya tingkat variasi pengukuran oleh pengaruh penekanan probe, pengukuran VFR feeding-artery paska anastomosa akan menjadi pilihan yang lebih baik. Tujuan : Pengukuran VFR feeding-artery (arteri brakialis) sesaat paska anastomosa FAV apakah dapat menggantikan pengukuran VFR draining vein paska anastomosa sebagai prediktor dini terjadinya proses maturasi pembuatan FAV brakiosefalika. Subyek dan Metode : Subyek penelitian adalah pasien penyakit ginjal tahap akhir (PGTA) dengan diabetes melitus (DM) yang menjalani operasi pembuatan FAV brakiosefalika di tiga rumah sakit (RSCM, RS Hermina Bekasi, dan RS Hermina Depok) pada periode Juli 2019 - Maret 2020. Desain yang digunakan kohort retrospektif menggunakan data sekunder dari penelitian sebelumnya. Data yang diteliti meliputi : usia, jenis kelamin, tekanan darah, riwayat merokok, riwayat hipertensi dan hasil pengukuran USG doppler VFR arteri brakialis dan draining-vein preoperatif, paska anastomosa, 2 minggu dan 6 minggu post-operatif, berikut data subyek dengan FAV brakiosefalika yang telah mengalami maturasi dalam waktu 6 minggu sesuai kriteria NKFKDOQI. Selanjutnya dilakukan analisa statistik adanya korelasi VFR arteri brakialis dan draining-vein terhadap maturitas pembuatan FAV brakiosefalika serta ditetapkannya nilai cutoff VFR arteri brakialis paska anastomosa terhadap terjadinya maturitas FAV yang dibuat dengan memakai uji diagnostik grafik Receiver Operator Curve (ROC). Hasil : Dari total 71 subyek yang memenuhi kriteria inklusi dan eksklusi, terdapat 44 (61,97%) subyek yang telah matur pada 6 minggu post-operasi dan 27 (38,03%) yang belum matur. Pada analisa statistik didapatkan adanya korelasi VFR arteri brakialis (p < 0,001) dan draining vein (p < 0,001) paska anastomosa terhadap terjadinya maturitas FAV setelah 6 minggu post-operatif. Pada pengukuran ROC keduanya didapatkan nilai cut-off yang serupa 350 mL/menit terhadap terjadinya maturitas dengan tingkat sensitifitas yang tidak jauh berbeda 95,45% vs 90,91% dan spesifitas 85,19%. vs 92,59%. Kesimpulan : Sesaat paska anastomosa, volume flow rate arteri brakialis dapat digunakan sebagai prediktor untuk mengevaluasi risiko kegagalan maturitas FAV brakiosefalika sehingga dapat menggantikan pemeriksaan volume flow draining vein yang secara teknis sulit dilakukan.
Kata Kunci : arteri brakialis; fistula arterivenosa; maturitas; volume flow rate.


Background : Post-anastomous evaluation of the volume flow rate (VFR) of draining-vein with Doppler ultrasound is a new effort to improve the rate of failure of the arteriovenous fistula (AVF) maturation process, after knowing the limits of the predictive value of draining-vein VFR on the occurrence of AVF maturity, but because of the high level of measurement variation due to the influence of probe compression, post-anastomous feeding-artery VFR measurement would be a better choice. Objective : Measurement of VFR feeding-artery (brachial artery) immediately after AVF anastomosis can replace measurement of VFR draining-vein after anastomosis as an early predictor of the maturation process for making brachiocephalic AVF. Subjects and Methods : The subjects of the study were end-stage renal disease (ESRD) patients with diabetes mellitus (DM) who underwent surgery to brachiocephalic AVF creation in three hospitals (RSCM, Hermina Hospital Bekasi, and Hermina Hospital Depok) in the period July 2019 - March 2020 The design used was a retrospective-cohort using secondary data from previous studies. The data studied included the results of the brachial artery and draining-vein VFR Doppler ultrasound measurement pre-operative, post-anastomous, 2 weeks and 6 weeks post-operative, along with data on subjects with brachiocephalic AVF who had matured within 6 weeks according to the NKF-KDOQI criteria. Furthermore, statistical analysis was carried out on the relationship between brachial artery and draining-vein VFR to brachiocephalic AVF maturity and the determination of the brachial artery VFR cut-off value after anastomosis on the occurrence of AVF maturity which was made using the Receiver Operator Curve (ROC) diagnostic test Results : From a total of 71 subjects who met the inclusion and exclusion criteria, there were 44 (61.97%) subjects who were mature at 6 weeks post-surgery and 27 (38.03%) were immature. Statistical analysis showed that there was a correlation between brachial artery VFR (p < 0.001) and draining vein (p < 0.001) post-anastomosis on the occurrence of AVF maturity after 6 weeks post-operatively. In both ROC measurements, the cut-off value was similar to 350 mL/minute for the occurrence of maturity with a sensitivity level that was not much different from 95.45% vs. 90.91% and specificity of 85.19%. vs 92.59%. Conclusion : Immediately after the anastomose, the brachial artery volume flow rate can be used as a predictor to evaluate the risk of failure of the brachiocephalic AVF maturity so that it can replace the flow draining vein volume examination which is technically difficult to do.
Keywords : arteriovenous fistula; brachial artery; maturity; volume flow rate