Disertasi

Efek Alfacalcidol terhadap Imunosenesens: Kajian In vitro dan In vivo terhadap Regulasi IL-6, IL-10, Interferon Gamma dan Subset Limfosit T pada Pasien Usia Lanjut dengan Sindrom Frailty. = Effect of Alfacalcidol in Immunosenescence: In Vitro and In Vivo Study of IL-6, IL-10,  IFN and T Lymphocyte subsets in the elderly with Frailty Syndrome.

Latar Belakang: Alfacalcidol, sebuah vitamin D analog, potensial bermanfaat memperbaiki imunosenesens pada pasien usia lanjut dengan sindrom frailty karena bekerja sebagai anti inflamasi melalui Vitamin D Receptor (VDR) pada makrofag dan sel T Tujuan: Mengkaji efek pemberian alfacalcidol in vitro dan in vivo terhadap perubahan sitokin inflamasi (IL-6, IL-10 dan Interferon ) serta subset limfosit T (rasio CD4/CD8, persentase sel T CD 8+ CD28-) dari kultur Peripheral Blood Mononuclear Cell (PBMC) dan Immune Risk Profile (IRP) pada usila dengan sindrom frailty. Metode: Selama Januari sampai Juli 2017 di RS Cipto Mangunkusumo Jakarta, direkrut masing-masing 8 orang subyek usila fit, pre-frail dan frail dan 10 subyek dewasa sehat sebagai kontrol. Pada 34 subyek ini dinilai perubahan kadar IL-6, IL-10 dan IFN  yang diukur dengan kit ELISA dari supernatan kultur PBMC 24 jam yang distimulus Lipopolisakarida (LPS) 100 ng/ml dengan dan tanpa pretreatment alfacalcidol in vitro. Selain itu juga dilakukan uji klinis acak tersamar ganda dengan pemberian alfacalcidol 0,5 mcg 90 hari pada 110 subyek berusia lanjut lalu diamati perubahan kadar IL-6, IL-10 dan IFN ,  perubahan rasio CD4/CD8 dan persentase sel T CD8+ CD28- serta penilaian Immune Risk Profile. Dilakukan uji t tidak berpasangan untuk mengetahui perbedaan rerata kadar sitokin dan persentase populasi sel T dan uji chi square untuk menilai beda proporsi subyek dengan IRP positif. Hasil: Pada penelitian in vitro didapatkan rerata kadar 25 (OH)D serum yang semakin menurun seiring dengan perburukan status frailty. Alfacalcidol in vitro tidak menurunkan IL-6 dan IFN , namun meningkatkan IL-10 pada seluruh kelompok. Dari uji klinis didaparkan alfacalcidol 0,5 mcg selama 90 hari tidak menurunkan IL-6 (p=0,4) dan IFN gamma (p=0,001), namun mampu meningkatkan IL-10 (p=0,005) dan menurunkan rasio IL6/IL10 (p=0,008) . Alfacalcidol meningkatkan rasio CD4/CD8 dari 2,68 (SB 2,45) menjadi 3,2 (SB 2,9); p=0,001 dan menurunkan persentase CD8+ CD28- dari 5,1 (SB 3,96). menjadi 2,5 (1,5); p < 0,001. Karena karakteristik awal subyek dalam hal IRP tidak komparabel, efek alfacalcidol terhadap IRP belum dapat dinilai. Kesimpulan: Alfacalcidol memerbaiki imunosenesens dengan bekerja sebagai anti inflamasi melalui peningkatan IL-10 dan penurunan rasio IL6/IL-10 serta memerbaiki imunitas seluler melalui peningkatan rasio CD4/CD8 dan penurunan sel T supresor.
Kata kunci: Alfacalcidol, inflammasi, sel T, usia lanjut, frailty.



Introduction: Chronic low grade inflammation and dysregulation of cellular immunity are the cardinal signs of immunosenescence in elderly with frailty syndrome. Alphacalcidol, a vitamin D analog shows immunoregulatory potency as it works on the macrophage and T cell, to control inflammation and T cell dysregulation in the elderly. Objective: to determine the effect of alphacalcidol on inflammatory cytokines (IL-6, IL-10, IFN gamma) and T cell subsets (CD4/CD8 ratio and CD8+ CD28-) and Immune Risk Profile of the elderly with frailty syndrome. Methods: During January to August 2017, in vitro study was conducted involving 10 healthy adults volunteer and 8 elderly each in fit, pre-frail and frail category from Outpatient Clinics of Cipto Mangunkusumo Hospital Jakarta Indonesia using 24h-Peripheral Blood Mononuclear Cells (PBMC) culture supernatants to determine the change of IL-6, IL-10 and  IFN level measured by ELISA, following stimulation with Lipopolisaccharide (LPS) 100 nm, with and without pretreatment with alphacalcidol. A double blind randomized controlled trial (RCT) with allocation concealment, involving 110 elderly subjects was also conducted to measure the effect of 0,5 mcg alphacalcidol administration for 90 days on inflammatory cytokines (IL-6, IL-10,  IFN) from 24 h-PBMC culture supernatant, as well as CD4/CD8 and CD8+CD28- count and change of Immune Risk Profile. Statistical analysis was performed using t test to measure mean difference of cytokines and T cell count and chi square to measure proportion difference of IRP. Result: In vitro study using PBMC showed alphacalcidol administration did not decrease IL-6 level IL- (p=0,24) and  IFN (p=0,36), but it increased IL-10 (p=0,02). Of 110 subjects involved in the RCT consisting of 27 fit elderly, 27 pre- frail elderly and 56 frail elderly, it can be observed that Alphacalcidol 0,5 mcg for 90 did not decrease IL-6 (p=0,4) and  IFN (p=0,001), but increased IL-10 (p=0,005) and decrease IL6/IL10 ratio (p=0,008) . Alphacalcidol increased CD4/CD8 ratio from 2,68 (SD 2,45) to 3,2 (SD 2,9); p=0,001 and decrease CD8+ CD28- percentage from 5,1 (SD 3,96) to 2,5 (1,5); p < 0,001. Because of incomparability in baseline characteristics of IRP, the effect on IRP could not be concluded. Conclusion: Alphaacalcidol improves immunosenescense by increasing IL-10 and decreasing IL6/IL-10 ratio as well as improving cellular immunity through CD4/CD8 ratio increase and suppressor T decrease in elderly with frailty syndrome.
Keywords: Alphaacalcidol, inflammation, T cell, elderly, frail.