Tesis

Hubungan Blood Flow Rate Arteri Brakialis Proksimal dan Distal Anastomosis Dengan Ketepatan Pengukuran Blood Flow Rate Vena Outflow Pasca Fistula Arteriovenosa Brakiosefalika Pada Penyakit Ginjal Tahap Akhir = Correlation of Proximal and Distal Brachial Artery Anastomosis with the Accuracy of Blood Flow Measurement in the Outflow Vein after Brachiocephalic Arteriovenous Fistula in End-Stage Kidney Disease.

Latar Belakang : Penyakit ginjal tahap akhir (PGTA) mempunyai prevalensi secara global 13,4% (11,7-15,1%) dan memerlukan terapi pengganti ginjal (TPG) diperkirakan mencapai angka 4,902 hingga 7,083 juta jiwa. Hemodialisis merupakan TPG yang banyak dipilih saat ini. Fistula Arteriovenosa (FAV) merupakan pilihan akses vaskular terbaik bagi penderita yang menjalani hemodialisis. Akan tetapi, kegagalan maturasi FAV relatif tinggi akibat gangguan dari îflow dan/atau outflow. Pengukuran peningkatan Blood Flow Rate (BFR) pada arteri brakialis proksimal anastomosis, distal anastomosis dan vena outflow diharapkan dapat mengidentifikasi masalah inflow sekaligus outflow sebagai penyebab kegagalan maturasi FAV. Tujuan : Mengetahui hubungan peningkatan BFR pada arteri brakialis proksimal anastomosis, distal anastomosis dan vena outflow serta menentukan batasan peningkatan persentase untuk maturitas pada tindakan FAV brakiosefalika. Subjek dan Metode : PGTA yang menjalani operasi FAV brakiosefalika di RSCM, RS Hermina Depok dan RS Hermina Bekasi pada periode Februari 2024 – Mei 2024. Desain penelitian kohort prospektif menggunakan data primer. Data yang diteliti meliputi: usia, jenis kelamin, hipertensi, merokok, diabetes melitus, aterosklerosis, riwayat pemasangan catheter double lumen (CDL) dan hasil pengukuran USG doppler berupa diameter arteri brakialis, vena sefalika dan BFR arteri brakialis preoperasi serta BFR arteri brakialis proksimal anastomosis, distal anastomosis dan vena outflow (OV) segera setelah tindakan AVF, hari ke 7, hari ke 14 sampai minggu ke 6 kemudian data subjek di nilai yang mengalami maturasi dan gagal maturasi dalam 6 minggu sesuai kriteria rule of 6 dari NKF-KDOQI. Selanjutnya dilakukan analisa statistik adanya peningkatan BFR arteri brakialis dan vena outflow terhadap maturitas FAV brakiosefalika serta ditetapkannya nilai batasan peningkatan persentase sebagai prediktor maturase dengan memakai uji diagnostik grafik Receiver Operator Curve (ROC). Hasil : Dari total 45 subjek yang memenuhi kriteria inklusi dan eksklusi, terdapat 36 subjek yang mengalami maturasi dalam 6 minggu pascaoperasi. Dengan analisis multivariat uji t-tidak berpasangan, didapatkan diameter arteri brakialis dan vena sefalika nilai rerata > 2,5 mm dengan nilai BFR arteri brakialis preoperasi 66,22 ± 22,60 (p < 0,001). Didapatkan batasan nilai persentase peningkatan BFR arteri brakialis proksimal 167,23% pada hari ke-7 yang memprediksi keberhasilan maturitas FAV brakiosefalika setelah 6 minggu pascaoperasi dengan sensitivitas 58,3%, spesifisitas 87,5%, interval kepercayaan 97,3%. Nilai persentase peningkatan OV diatas 186,92% pada hari ke-7 dan diatas 468,0% pada hari ke-14 dapat memprediksi keberhasilan maturitas FAV pada minggu ke-6 dengan sensitifitas dan spesifisistas sebesar 61,1% dan 100% untuk hari ke-7 dan 80,6% dan 100% untuk hari ke-14 Kesimpulan : Peningkatan persentase BFR arteri brakialis proksimal anastomosis dan vein outflow hari ke-7 pasca tindakan FAV dapat dipakai sebagai prediktor maturitas FAV brakiosefalika.
Kata Kunci : Arteri Brakialis, Blood Flow Rate, Fistula Arteriovenosa Brakiosefalika, Vena Outflow, Maturasi.


Background : End-stage kidney disease (ESKD) has a global prevalence of 13.4% (11.7- 15.1%) and requires kidney replacement therapy in approximately 4,902 to 7,083 million peopl. Hemodialysis is the most widely used kidney replacement therapy. Arteriovenous fistula (AVF) is the best vascular access option for patients undergoing hemodialysis. However, the failure rate of AVF is relatively high due to inflow and/or outflow obstruction. Measurement of increased blood flow rate (BFR) in the brachial artery proximal anastomosis, distal anastomosis, and outflow vein is expected to identify both inflow and outflow problems as a cause of AVF maturation failure. Objective: To determine the relationship between the increase in BFR at the proximal brachial artery anastomosis, distal anastomosis, and outflow vein and to determine the limits of percentage increase for maturation in AVF brachiocephalic measurements. Subjects and Methods: ESKD who underwent AVF brachiocephalic surgery at Ciptomangunkusumo hospital, Hermina Depok Hospital and Hermina Bekasi Hospital in the period February 2024 - May 2024. The prospective cohort study design using primary data. The data studied included: age, gender, hypertension, smoking, diabetes mellitus, atherosclerosis, history of double lumen catheter insertion and Doppler ultrasound measurement results in the diameter of brachial artery, cephalic vein and preoperative BFR brachial artery. Further BFR proximal anastomosis brachial artery, BFR distal anastomosis and BFR venous outflow (OV) immediately after AVF procedure, day 7 , day 14 to week 6 , then the subject data were evaluated for maturation and immature in 6 weeks according to the rule of 6 criteria of NKF-KDOQI. In addition, statistical analysis of the increase in BFR of the brachial artery and outflow vein on the maturation of the brachiocephalic FAV was performed, and the cut-off value of the percentage increase was determined as a predictor of maturation using the Receiver Operator Curve (ROC) graph diagnostic test. Results: From a total of 45 subjects who met the inclusion and exclusion criteria, there were 36 subjects who matured within 6 weeks postoperatively. With multivariate analysis of unpaired t-test, the mean diameter of brachial artery and cephalic vein was > 2.5 mm with preoperative BFR brachial artery value of 66.22 ± 22.60 (p < 0.001). The percentage increase in BFR proximal brachial artery of 167.23% at day 7 predicted successful maturation of AVF brachiocephalic at 6 weeks postoperatively with a sensitivity of 58.3%, specificity of 87.5%, confidence interval of 97.3%. The percentage value of OV increase above 186.92% on day 7 and above 468.0% on day 14 can predict the success of AVF maturity at week 6 with sensitivity and specificity of 61.1% and 100% for day 7 and 80.6% and 100% for day 14. Conclusions: Increased percentage of BFR of proximal brachial artery anastomosis and venous outflow on day 7 after AVF can be used as a predictor of brachiocephalic FAV maturity. Keywords: Brachial artery, blood flow, brachiocephalic arteriovenous fistula, venous outflow, maturity.